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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone, four pills daily for treatment of the enrollee who has history of chronic back pain. Fulfills Findings:  The physician reviewer found that the documentation provided does not support the requested medication quantity in this clinical setting. Several requirements for opioid prescribing have not been documented as performed. Objective treatment goals for pain and function are not noted for the requested medication and several recent requirements for opioid prescribing have not been documented. So, the need to use them as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or greater MME per day. It is recommended to carefully justify a decision to titrate dosage to 90 or greater MME per day. In this case, the patient was recently taking 320 MME per day. There is no objective medical evidence based rationale given by the provider or the patient. There were no long term consequences discussed with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 320 MME per day. It is unclear what the plan is for any unseen future pain the patient would experience while on 320 MME per day. Also, it is clear that tolerance has taken place since the start of the narcotics. Moreover, the providers involved with the case know dose escalation is not a long term plan but a short term plan for the treatment of tolerance. These increases are especially worrisome since not all other non-pharmacological ways of taking care of the pain have been done or even addressed. There is no mention of completion of behavior therapy documented to be done despite much research to support its use. Finally, not all non-opioid medications have been optimized or tried. For all these reasons, the requested authorization and coverage for methadone, four pills daily, is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication quantity 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 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.