Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a change in dosage of the medication Percocet 10/325 to 8-10 tablets a day.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that when opioids are started, clinicians should prescribe the lowest effective dosage. CDC guidelines state that clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to =50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to =90 MME/day or carefully justify a decision to titrate dosage to =90 MME/day. The guidelines also state that benefits of high-dose opioids for chronic pain are not established. The guidelines further indicate that they found no difference in pain or function between a more liberal opioid dose escalation strategy and maintenance of current dosage. The guidelines also concluded that the clinical evidence review found that higher opioid dosages are associated with increased risks for motor vehicle injury, opioid use disorder, and overdose. The clinical and contextual evidence reviews found that opioid overdose risk increases in a dose-response manner.Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the patient has been prescribed Percocet tablets 10/325 mg up to five times daily as needed for pain. The patient has requested an increase in dosing to allow 8-10 tablets per day as needed for pain. The patients healthcare provider has stated in the medical records that low dose therapy is indicated for the patients chronic abdominal pain due to Crohns disease. The provider has not recommended or prescribed high dose therapy associated with an increase to 8-10 tablets daily. The provider stated that there were concerns of opioid tolerance related to high dose therapy. The CDC guidelines confirm that high dose opioid therapy has not been shown to be more effective for managing chronic pain, but has been shown to be associated with increased risks including overdose. Under these circumstances, the requested change in dosage of the medication Percocet 10/325 to 8-10 tablets a day is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested change in dosage of medication is not medically necessary to treat the patients 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.