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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg, five tablets per day.Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing for chronic pain state that 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. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.Federation of State Medical Boards guidelines for the Chronic Use of Opioid Analgesics recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. Guidelines state that patients should maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met.American Society of Interventional Pain Physicians guidelines state that prescribing of opioids less than 40 morphine equivalents a day is consider low dose therapy. 50 to 90 morphine equivalents per day is consider moderate dose therapy.In this case, the patient has degenerative disc disease involving all three levels of the spinal column with canal stenosis in the lumbar spine. The patient has signs and symptoms of right cervical radiculopathy and right lumbar radiculopathy. She has tried and failed epidural steroid injection therapy as well as physical therapy. The patient is currently awaiting approval for a spinal cord stimulator trial and has been attempting to manage her pain with Norco 10/325 mg five tablets per day. There is no indication in the medical records of provider concerns of opioid use disorder or any inconsistencies in the CURES reports, and the provider notes suggest that the patient is able to function better with opioid therapy. While there is no clear documentation in the records of the necessity of five tablets of Norco daily, based on the current national guidelines, the patient does have acceptable indications for chronic opioid therapy and has been compliant with non-opioid treatment options. The request for five tablets daily, however, places the patient above the CDCs recommended threshold of 50 morphine equivalents per day. Under these circumstances, the request for Norco is medically necessary to treat the patients medical condition up to a maximum of 4 tablets per day. Accordingly, the requested medication Norco 10/325 mg at a dosage of five tablets per day is not medically necessary for the patients medical condition. However, the requested medication Norco 10/325 mg at a dosage of four tablets per day is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.