Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 5-325 mg (one tablet every six hours) for treatment of the enrollees ankle pain.Findings: The physician reviewer found that the review of the submitted documentation supports the medical necessity for the request for Norco 5-325 mg (one tablet every six hours). In this case, the patient presents with chronic ankle pain after an injury occurring nearly six months ago with re-injury.  The patient has also been treated for chronic nonmalignant pain including low back, pelvic, and abdominal pain with Norco. In terms of the patients medications, opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. 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 small a benefit for osteoarthritis. Nonsteroidal anti-inflammatory drug (NSAID) medications have very small analgesic effects and warnings about the cardiovascular risks. In this case, the patient has a history of gastroesophageal reflux disease as well as allergy to tramadol which limit her medication options. 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. The patient has been prescribed Cymbalta without a clear diagnosis of neuropathic pain. In support of prescribing opioids, controlled trials have shown a modest effect in terms of analgesia with opioids. Judicious prescribing and monitoring remains a viable option for selected patients. In this case, there is a lack of documentation demonstrating issues of abuse or addiction. There is no evidence of a violation of an opioid agreement or 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. 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 including the pending physical therapy treatments. For the reasons provided, the request for Norco 5-325 mg (one tablet every six hours) has been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication 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.