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

The enrollee is requesting authorization and coverage for the medication, Suboxone. The enrollee has a history of complex regional pain syndrome (CPS) type 2 and mood difficulties that have been responsive to psychotropic medications. The enrollee has been on pain medications for about five years and was on a high dose of opioids prior to her enrollment in the pain management program, Opioid Safety Program (OSP), in order to taper-off from her opioid medications. The enrollee is highly motivated to get-off of her opioid medications completely. According to the OSP note, the starting daily Morphine Milligram Equivalent (MME) was 210.  The providers notes indicate the enrollee has been tolerating the tapering well, until she reached her daily MME of 165. Based on a note, the enrollee was down to six Oxycodone 10mg tabs/day and 45mg/day Morphine per Controlled Substance Utilization, Review and Evaluation System (CURES) refill history (90+45MMED) but the enrollee feels the withdrawal symptoms. The provider discussed with the enrollee that switching to Suboxone would not be in her best interest to taper off opioids, as the tapering dose decreases from Suboxone would be a larger MME compared to the short acting opioids, and also the enrollee was not keen on the Chemical Dependency Treatment part that would be a mandatory part of a Suboxone regimen. Review of the record indicates the enrollee is requesting a long-acting medication, Suboxone, that can reverse the tapering process by increasing the daily Morphine Milligram Equivalent (MME) intake and potentially worsen her physiologic dependency to opiates. The enrollee has chronic pain syndrome and history of depression. As per psychiatry notes, the enrollees history of childhood trauma places her at a greater risk for other mental illness. Considering her history, the literature for managed withdrawal recommends not only medication, but also psychological and lifestyle counseling, support groups and medical treatment. A literature review indicates managed withdrawal is considered a necessary step prior to drug-free treatment. While Suboxone is FDA-approved for the use of medication-assisted treatment (MAT) to manage opioid withdrawal, in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion, psychosocial support and behavioral therapy  (Chemical Dependency Treatment) are needed for successful treatment of opiate-tapering. The physician reviewer found that  records indicate the enrollee is requesting a medication that would reverse her tapering progress and potentially worsen her physiologic dependency to opiates since the requesting long-acting Suboxone dose will be higher than her current physiologic daily need of an opiate. In order to prevent opiate relapse, the enrollees provider recommended Chemical Dependency Treatment, which is a mandatory part of the Suboxone regimen. Contrary to the enrollees high motivation to quit, she is refusing her providers recommendations for managed withdrawal, which includes both medication and counseling and behavioral therapies to increase the likelihood of achieving opiate-free status.