Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Oxycontin and magnetic resonance imaging (MRI), spinal canal and contents, thoracic; without contrast for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Argoff and Silvershein note that for chronic non-cancer pain, short and long acting opioid has been found to be effective. A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. Noting as well that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. According to Nicholson opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. In this case, the patient has not completed intervention for her pain. The patient also has chronic medical issues. Oxycontin is not medically necessary, as the patient has not been on a consistent dosing regimen of a short-acting medication to see how she is able to tolerate the dosing given the issues with her medical condition and specific elevated organ function tests.  In regards to the requested MRI, according to AIM Specialty Health Clinical Appropriateness Guidelines for imaging of the spine In a patient where focused history and physical exam suggest non-specific thoracic pain and/or referred posterior chest pain and all of the following are met: patient is a potential candidate for surgery or epidural steroid injection; patient has, following clinical examination, completed a number of consecutive weeks of physician supervised conservative therapy for the current episode of pain, including but not limited to any of the following: [nonsteroidal anti-inflammatory drugs] NSAIDs, muscle relaxants, steroids, physical therapy; and after trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical re-evaluation; or mid-back pain not meeting the above criteria but associated with red flag symptoms such as unexplained weight loss, history of malignant disease, fever, drug abuse, or tuberculosis, abnormal labs suggestive of malignancy such as abnormal serum or urine electrophoresis, elevated prostate specific antigen (PSA). In this case, there is no notation of the patient having tried and failed physical therapy. In addition, the patient has tried one narcotic regimen with negative x-rays noted. In sum, based on the documentation submitted for review, there are no acute symptoms or red-flags as noted on the imaging recommendations above. Final Result: The reviewer determined that the requested services are 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.