Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right carpal tunnel syndrome and complex regional pain syndrome (CRPS).  The provider noted that the patient underwent a right carpal tunnel release that was complicated by a postoperative infection requiring an incision and drainage procedure. The provider noted the patient had findings consistent with CRPS, including hyperhidrosis of the right-hand fingers, shiny skin, and nerve pain with proximal radiation. The patient was previously treated with a stellate ganglion block, which reportedly was not beneficial. The patient has also been treated with Lyrica and Valium. The patient was noted to be allergic to Pamelor, and she did not want to try another nerve pain medication. The provider noted a second surgery to release scar tissue could be beneficial. The patient requested an increase of her 5 mg Valium dosage to 10 mg and reported taking two 5 mg Valium tablets at once. A refill for Valium 5 mg, 15 tablets was sent to the patients pharmacy. The patient has requested authorization and coverage for Valium 10 mg two times daily for three months. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Valium 10 mg two times daily for three months is medically necessary for the treatment of the patients medical condition. According to the U.S. Food and Drug Administration (FDA), Valium is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The FDA reported, The effectiveness of Valium in long-term use, that is, more than four months, has not been assessed by systematic clinical studies. The physician should periodically reassess the usefulness of the drug for the individual patient. The FDA did not report Valium is indicated for the treatment of CRPS or chronic pain. Misidou and Papagoras reported that certain classes of medications are indicated for the treatment of CRPS, including non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates, vitamin C, dimethyl sulfoxide (DMSO) and phenoxybenzamine. There was no evidence or discussion presented on the utility of Valium for treating CRPS. Goh and colleagues described several current standard treatments for CRPS, including physical therapy, psychological treatments, pharmacological therapies, as well as interventional treatments including sympathetic blockade and surgical approaches. The use of Valium for the treatment of CRPS was not discussed. In this case, the patient has been diagnosed with CRPS after undergoing carpal tunnel release surgery. She was treated with a combination of Lyrica and Valium as well as failed treatments with Pamelor and stellate ganglion blocks. The patient reported taking two 5 mg Valium tablets at once and requested an increase in her Valium dosage to 10 mg. There is no evidence in the medical literature to support the use of Valium for the treatment of CRPS. The FDA reported, Generally milder withdrawal symptoms (e.g., dysphoria and insomnia) have been reported following abrupt discontinuance of benzodiazepines taken continuously at therapeutic levels for several months. Consequently, after extended therapy, abrupt discontinuation should generally be avoided and a gradual dosage tapering schedule followed. The medical evidence does not support the requested medication in this clinical setting. Therefore, Valium 10 mg two times daily for three months is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.