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 (Percocet) 10 mg, six times a day or oxycodone (Percocet) 10 mg, five times a day. The submitted documentation does not support the medical necessity of the requested medication. 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 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. Further, the FSMB strongly recommends prescribers use 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. In this case, the patient has a history of chronic pain that in the past had been treated with opioid therapy. The records documented a history of three inconsistent urine drug results and an episode of accidental opioid overdose in 2019. The patients providers have recommended discontinuing opioid therapy, and the records do not include any plan by the treating providers to restart the patient on opioid therapy. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, oxycodone (Percocet) 10 mg, six times a day is not medically necessary for the treatment of this patient. Additionally, oxycodone (Percocet) 10 mg, five times a day is not medically necessary for the treatment of this patient. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly and the eligible patient is advised to speak with their treating physician. The treating physician and the eligible patient should decide upon an opioid reduction program. It is beyond the scope of the IMR process to specify a specific tapering schedule. The treating physician and the eligible patient are advised to consult the Centers for Disease Control and Prevention (CDC) Guide to Tapering Opioids that provides further opioid weaning guidance.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.