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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Subutex. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee medical history.Findings: The documentation provided does not support the medical necessity for the requested medication in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings (Raffa and Pergolizzi). However, in the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. The Centers for Disease Control and Prevention (CDC) guideline states when opioids are started, providers should prescribe the lowest effective dosage. When starting opioid therapy for chronic pain, providers should prescribe immediate release opioids instead of extended release/long acting opioids. Additionally, when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  In this case, the patient has requested 180 MME/day. There is no medical evidence based rationale supporting this high of a dose. Additionally, the medical literature indicates that there are long term consequences with the continual increase in dose. Risk and benefit analysis must be performed to justify the requested level of 180 MME/day. It is unclear from the records what the plan is for any unseen future pain insults the patient would experience while already on 180 MME/day. Moreover, it does not appear that all other non pharmacological treatment options for taking care of the pain have been provided or addressed. There was no mention of cognitive behavior therapy for pain documented despite much research to support its use. The medical literature recommends consideration of alternatives to opioids and to wean the patient to a lower dose of opioids or off opioids all together. Finally, not all non opioid medications classes have been noted to be optimized. The provider also noted a plan to start Lyrica. The medical necessity for the requested medication has not been established in this clinical setting. For all these reasons, Subutex is not medically necessary for treatment of this patients medical condition.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-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.