Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for OxyContin provided, and future for OxyContin 60 mg three times per day (90 tablets per 30 days) for a total of 12 consecutive months without interruption. Findings:  The physician reviewer found that records provided for review document that this patient presents with multiple diagnoses, including trigeminal neuralgia, fibromyalgia, degenerative disc disease, and chronic migraines. The patient has been treated on a long-term basis with high doses of OxyContin. The patient has requested continued treatment with OxyContin. Opioids are typically not recommended for the treatment of patients with fibromyalgia or chronic migraines. Various medications such as calcitonin gene-related peptide (CGRP) antagonists are available for the treatment of chronic migraines and these medications have been demonstrated to be more effective and well tolerated than opioids with fewer associated risks. Medications such as carbamazepine and oxcarbazepine are considered first-line therapies for patients with trigeminal neuralgia. There are significant risks with long-term opioid therapy even when opioids are included as part of the treatment plan. Chronic opioids at high doses can cause opioid induced hyperalgesia. For this patient, the dose of opioids being requested is unlikely to be beneficial compared to evidence-based treatment options and could be worsening the patients pain due to opioid induced hyperalgesia. All told, OxyContin provided, and future for OxyContin 60 mg three times per day (90 tablets per 30 days) for a total of 12 consecutive months without interruption was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the OxyContin provided, and future for OxyContin 60 mg three times per day (90 tablets per 30 days) for a total of 12 consecutive months without interruption was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. The reviewers are experts 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.