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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the patient has a history of chronic neck pain and has been on chronic opioid therapy for six years, which was initiated by the previous healthcare provider who has since retired. The patients new provider reviewed his medical records and felt that the risk-benefit ratio of continued opioid therapy was unfavorable based on the patients diagnosis and physical examination. The treating provider recommended that the patient wean off of Norco and change the treatment plan focus to non-opioid and nonpharmacological treatment options, which is consistent with the current CDC guidelines. The treating provider attempted to refer the patient for physical therapy, acupuncture and CDRP, however, the patient has been noncompliant with the referral to CDRP. In addition, the treating provider had concerns regarding the patients admitted self-prescribing behavior, which has led to requests for early refills on the patients Norco medication and has raised concerns for possible opioid dependence. Current national guidelines suggest that patients who display aberrant behavior regarding their opioid prescriptions should be reviewed for possible tapering and discontinuation of opioid therapy due to an unfavorable risk-benefit ratio. Under these circumstances, the patients treating providers have recommended care that is consistent with current guidelines. Accordingly, the requested Norco is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.