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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen 10-325 mg (#120 tablets per 30 days, one tablet every six hours as needed with six refills). The submitted documentation does not support the medical necessity of the requested medication. Manchikanti and colleagues state, To establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary. These include non-controlled substance therapy, physical modalities, behavioral interventions, interventional pain management techniques, and any other alternatives. The authors further state, It is essential to establish medical necessity prior to initiation or maintenance of opioid therapy based on average, moderate or severe (greater or equal to four on a scale of zero to ten) pain and/or disability. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The authors further note, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. 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. The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient has chronic pain from a previous back surgery that was aggravated by a mechanical fall. The provider noted diagnoses of lumbar degenerative disc disease and lumbar strain.  The provider noted that the patient reported restarting Percocet but did not document the prescriber or the length of time of use. The provider recommended an updated lumbar radiograph and follow-up with neurosurgery, and the documentation from this encounter did not note that that further Percocet prescriptions were indicated or prescribed. The records did not include documentation of validated pain scores or past or current Controlled Substance Utilization Review and Evaluation System (CURES) checks or urine drug screens. The records also document that the patient was diagnosed with a fractured nose during an emergency department visit. There is no new information outlining active prescriptions for oxycodone from a pain specialist or primary care provider. In this clinical setting, given the lack of documentation of a recent assessment from any provider recommending opioid therapy, the requested medication is not medically indicated. Therefore, oxycodone-acetaminophen 10-325 mg (#120 tablets per 30 days, one tablet every six hours as needed with six refills) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 sub-specialty 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.