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

Nature of Statutory Criteria/Case Summary: The patient is a male diagnosed with cauda equina syndrome, chronic low back pain, and lumbar radiculopathy. The patient underwent lumbar discectomy surgery. The patient has a history of frequent emergency department visits. The patient presented to the emergency department and reported suicidal ideation. The patient was placed on an involuntary hold due to being high risk for self-harm. The patient admitted to abusing alcohol and medications. A urine drug screen detected methadone, methamphetamines, and cocaine. An emergency department report noted the patient was behaving in an aggressive manner. An emergency department report, noted the patient presented for acute alcohol intoxication, at which time he reported that he was being treated at a suboxone mobile clinic with buprenorphine for substance abuse disorder. The patient has requested coverage for methadone 10mg, 120 pills every 30 days and Percocet 2.5mg, 150 pills every 30 days. The Health Plan denied the requested medications as not medically necessary for the treatment of this patient. At issue in this case is whether the requested methadone 10mg 120 pills every 30 days and Percocet 2.5mg, 150 pills every 30 days are medically necessary for treatment of the patients medical condition. The American Society of Addiction Medicine (ASAM) guidelines recommend caution with using methadone for patients with active substance use disorder who are also using sedatives. In this patients case, the ASAM guidelines would advise caution, as he has presented on multiple occasions while under the influence of alcohol. In addition, the medical records noted the patient had suicidal ideation and was placed on an involuntary hold due to being at high risk for self-harm. The Guidelines for the Chronic Use of Opioid Analgesics states that patients with untreated depression and other mental health disorders are at increased risk for misuse or abuse of controlled medications, including addiction and overdose. The patient reported receiving treatment for substance use disorder with buprenorphine, for which there is no record in the chart. Further, the patient was noted to have behaved in an aggressive manner while under the influence of alcohol and medications. Overall, patients should be tapered or weaned off chronic opioid therapy when they engage in serious or repeated aberrant drug related behaviors or diversion, experience intolerable adverse effects, or make no progress toward meeting therapeutic goals. Providers should continue opioid therapy only if there is improvement in action that outweighs risks to patient safety. Therefore, the request for Methadone 10mg, 120 pills every 30 days and Percocet 2.5mg, 150 pills every 30 days are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications are 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 a subspecialty certification in pain management 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.