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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 5/325 mg, one to two tablets every four to six hours. The American Society of Interventional Pain Physicians (ASIPP) guidelines for opioid treatment of chronic non-cancer pain recommend chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events. A study stated appropriate opioid prescribing requires a thorough patient assessment, short and long-term treatment planning, close follow-up, and continued monitoring. All providers need to be aware of not only appropriate patient assessment and treatment planning but also the possibility of use disorder, diversion, and potentially dangerous behavioral responses to controlled substances. Colleagues  noted risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. The patient presents with progressively worsening left knee pain. He has been diagnosed with severe osteoarthritis. He is scheduled for a total knee replacement. His orthopedic surgeon has declined to prescribe preoperative opiate medication. His primary care provider also has declined to prescribe opiate medication for chronic pain. He has been utilizing over-the-counter ibuprofen and Tylenol, without benefit. Other conservative treatment has been recommended, including physical therapy, activity modification, and glucosamine. He was prescribed a short course of Norco in a recent urgent care visit, without documentation of a specific pain or functional improvement associated with this medication. This patient has potential risk factors for opioid misuse that require evaluation by the prescribing provider before initiation of Norco. Additionally, it is not clear that all other medications have been considered and have failed, such as a prescription strength non-steroidal anti-inflammatory drug. It is expected that the treating provider will follow evidenced-based medication guidelines for safe weaning and discontinuation. Therefore, Norco 5/325 mg, one to two tablets every four to six hours 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 orthopedic surgery 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.