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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin 20 mg tablet extended release 12 hour for treatment of the enrollees back pain. Findings:  The physician reviewer found that The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. The CDC states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. In this patients case, a treatment plan was not provided including a plan to taper down opioid use. The records do not provide medical evidence based rationale by the provider for the increase in the medication. There was no indication that long term consequences with the continual increase in opioids were discussed. Risk and benefit analysis must be performed to justify the requested level of 90 morphine milligram equivalents (MME) per day. Also, it is clear that tolerance has taken place since the start of the narcotics, as just a few months ago 60 MME/day was sufficient and 45 MME/day before that. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There is also the possibility, in this case, of opioid induced hyperalgesia. The provider did not indicate a clear objective goal for this high opioid dose. The medical literature states that prior to increases in medication dosage, all other non-pharmacological ways of taking care of the pain should be addressed. In this patients case, there does not appear to be a completion of behavior therapy despite much research to support its use. Finally, not all non-opioid medications have been optimized or tried.  For all these reasons, OxyContin, 20 mg tablet ER, is not medically necessary for treatment of the patients medical condition.  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.