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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets, quantity of 120 tablets per month, taken as one (1) tablet by mouth every 6 hours as needed.Standard therapy for rheumatoid arthritis/psoriatic arthritis includes the use of biologic drugs and DMARDs which are immunosuppressive therapies and carry the risk for infection. Due to a history of the left knee prosthetic joint infection, the patient has chosen to avoid biologic drugs and other DMARDs and is currently on hydrocodone-acetaminophen, which is an opiate, a controlled substance, to control chronic joint pain.Opioid pain medication use presents serious risks, including overdose and opioid use disorder. Prescription drug monitoring programs are state-level databases into which prescribing health care providers and pharmacists must enter prescription information when controlled medications are dispensed. Medical staff may access these data as permitted by state laws to obtain timely information on the dispensing on controlled drugs for individuals. Prescription Drug Monitoring Programs are in place to reduce prescription opioid-related harm by identifying patients who might benefit from targeted health interventions and detecting patients and prescribers engaged in illegal activities. Prescription Drugs Monitoring Programs are associated with safer prescribing practices and lower rates of prescription opioid use and fatal overdose.The CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016 recommends that health care providers review an individual's history of controlled substance prescriptions via a Prescription Drug Monitoring Program to determine whether the individual being prescribed therapy is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. It is recommended that health care providers review Prescription Drug Monitoring Program data when starting opioid therapy for chronic pain and periodically ranging from every prescription to every 3 months.In addition, the CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016 also recommends health care providers use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed opiate medications as well as other controlled prescription drugs and illicit drugs. It is recommended that health care providers use urine toxicology results to improve patient safety. Based on urine drug screening results, providers may continue therapy or determine that opiate therapy should be tapered/discontinued, offer naloxone, or provide referral for treatment of substance use disorder.In this case, there is a lack documentation of appropriate urine drug screening and documentation of Prescription Drug Monitoring Program data. Without this documentation, the patients use of the requested medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets would be inconsistent with CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016. Accordingly, the requested medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets, quantity of 120 tablets per month, taken as one (1) tablet by mouth every 6 hours as needed, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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.