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

Nature of Statutory Criteria/Case Summary: The patient has a medical history of cervical stenosis with myelopathy, lumbar stenosis with myelopathy, severe obesity, and osteoarthritis. He underwent a lumbar epidural steroid injection at L5-S1 in August 2017, and was evaluated by a neurosurgeon. He was advised to proceed with cervical surgery but he did not wish to proceed due to concern of worsening pain and disability after surgery. The provider indicated that cervical epidural steroid injection was not indicated due to stenosis, and the procedure might worsen symptoms. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spines showed moderate central canal stenosis at C3-4 with cord changes consistent with myelopathy, mild to moderate canal stenosis at T4-5, and moderate to severe canal stenosis at L3-L4. The provider noted in December 2018 that the patient had a limited ability to walk due to pain and claudication symptoms. The patient noted effective pain control with Percocet 5/325 three times a day for many years. There had not been requests to increase medication. Medications for chronic pain also include gabapentin, cyclobenzaprine, and meloxicam. He has been compliant with urine drug screening testing, and prescribed physical therapy. There is a signed opioid medication agreement in his chart.The Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing for chronic pain state that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Furthermore, the guidelines suggest that if opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. After review of imaging reports and notes from the provider, this patient does have adequate documentation of moderate to severe spinal cord pathology, along with symptoms of neurogenic claudication. The patient has been compliant with opioid monitoring requests and a multimodal pain management program. He is not considered a surgical candidate. He experienced limited benefit with lumbar epidural steroid injections. His provider noted that further interventions are not advisable at this time due to the severity of his spinal stenosis. The patient appears stable on Percocet 5/325mg three times a day for pain control, and reports that opioid therapy does allow him to perform his activities of daily living without adverse side effects. There is no documentation for requests to increase pain medications nor is there any concern in the provider notes regarding aberrant behavior. The 2019 American Society of Interventional Pain Physician (ASIPP) opioid therapy guidelines suggest that opioid therapy that is under 40mg morphine equivalent is considered low dose. The patients current opioid requirement is 22.5mg per day. Given this support, the requested Percocet 5mg tablet every eight hours is medically necessary for treatment of this patients chronic pain.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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.