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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment with a pain management specialist and either Dilaudid or morphine. The Centers for Disease Control and Prevention (CDC) guidelines 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. Similarly, the Federation of State Medical Boards guidelines noted that, 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 addition, the American Society of Interventional Pain Physicians (ASIPP) advise that provider establish medical necessity by establishing appropriate physical diagnosis and psychological diagnosis if available. ASIPP supports a pain management consultation to assist non-pain physicians, if high-dose opioid therapy is utilized. In this case, the patient has multiple pain complaints, including chronic neck pain with confirmation of multilevel spondylosis and mild canal stenosis on cervical MRI. The patient was involved in a motorcycle accident in 2015 and a motor vehicle accident in 2019. He reports right elbow pain and MRI demonstrated lateral epicondylitis with possible tears of the extensor compartment of the elbow. Treatment has included Norco, gabapentin, tramadol, and Tylenol #3. However, the records document that the patient has exhibited aberrant and abusive behavior toward staff at his providers offices. The current guidelines recommend re-evaluation and possible discontinuation of opioids for patients who demonstrate inappropriate or high-risk behavior. The patients current provider has advised a treatment plan involving physical therapy and nonopioid medication management. Based on the presence of degenerative changes in the cervical spine and findings of lateral epicondylitis in the right elbow, a referral to a pain management specialist is indicated to assist with implementation of a nonopioid based pain management treatment plan for this patient. All told, the requested treatment with a pain management specialist is medically necessary for this patient, while the requested Dilaudid and morphine are not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 management 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.