Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for methadone 10 mg five pills per day. The Health Plan has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees chronic low back pain.The records indicate that this patient is being treated for chronic non-malignant pain. In terms of the patients medications, opioid medication can be considered as part of the standard of care when treating patients with chronic non-malignant pain. Concern for opioid misuse can result in undertreatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. The analgesic options for patients with chronic pain have steadily declined. Acetaminophen has been found to have minimal efficacy for low back pain and only a small benefit for osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) have small analgesic effects and warnings about the cardiovascular risks have been strengthened by the U.S. Food and Drug Administration (FDA). In this case, the patient is over age 65 and at increased risk of a gastrointestinal event with use of NSAIDs. Several classes of medications such as gabapentin and serotonin-norepinephrine reuptake inhibitor (SNRI) medications are approved for neuropathic pain and fibromyalgia but it is unclear if they are effective for the broader group of patients with low back pain, arthritis, and other musculoskeletal pain disorders. Tricyclic antidepressants and muscle relaxants are often used as adjunctive pain treatments but have a relatively weak evidence-based for treating chronic pain. Further, alternative therapies such as acupuncture, yoga, meditation, chiropractic care, massage, and cognitive behavioral therapy are not considered a standard replacement for analgesic medications. In this case, the patient had been taking methadone on a long-term basis. There is evidence of an attempt at weaning with worsening pain as well as possible symptoms of withdrawal due to tapering too quickly. There is no documentation of issues of abuse or addiction. There is no evidence of a violation of an opioid contract, refusal to participate in urine drug screening, or completion of readily available tools used in the assessment of pain and function. There is no evidence of a plan to provide another medication in the same class at an equivalent morphine equivalent dose (MED). Although conservative treatments are available, these treatments do not require the discontinuance of the patients opioid medication and continuing to prescribe this medication may facilitate any available alternative treatments being considered. The discontinuation of medication at the dose that had been effective is not appropriate. Without identifying an appropriate, safe, and agreed upon alternative plan, ongoing prescribing at the 10 mg dose, five times per day which has been both effective and well tolerated is medically necessary for the treatment of the patients medical condition. For these reasons, the requested methadone 10 mg five pills per day is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.