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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the medication oxycodone hydrochloride extended release. Findings:  The physician reviewer found that  guidelines for the prescribing of opioids for chronic pain state that nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. The guidelines state that 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. The Federation of State Medical Boards Guidelines for the Chronic Use of Opioid Analgesics recommends that opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, be utilized only when non-opioid and non-pharmacological options have not been effective. Providers should maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met.In this case, the patient had chronic low back pain with intermittent flare ups of this problem. The patient presented to his healthcare provider and was diagnosed with right lumbar radiculopathy due to L4/5-disc herniation. The patient had tried and failed PT, NSAIDs and Hydrocodone. The provider stated in his note that he did not feel that chronic opioid therapy was appropriate and recommended treatment with a neuropathic agent along with epidural steroid injections. Records reflect that the patient had never completed a trial of neuropathic medication before. The patient, however, purchased an initial prescription of oxycodone hydrochloride extended release to manage his pain despite it not being recommended in his treating providers plan. Both the CDCs current guidelines and recommendations from the Federation of State Medical Boards do not recommend the usage of extended-release formulations for patients with chronic pain without first trialing non-opioid and non-pharmacologic options. Under these circumstances, the medication oxycodone hydrochloride extended release at issue was not medically necessary for the patients medical condition.Final Result: The reviewer determined that the medication at issue was not medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be upheld.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.