Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with dorsalgia, low back pain, right shoulder pain, and osteoarthritis. Imaging of the right shoulder revealed advanced osteoarthritis of the glenohumeral joint that had progressed since September 2017.  The provider noted the patient has previously been treated with acupuncture, chiropractic treatment, injections, physical therapy, and massage. The provider noted the patients pain was being treated with a combination of Norco 10/325 mg, Celebrex, ibuprofen, and acetaminophen with poor pain relief. The provider noted that the treatment plan includes tapering the Norco and transitioning to buprenorphine patches. The patients surgical history included hip replacement surgery in 2008. The patient has requested authorization and coverage for buprenorphine transdermal patches, 10 mcg/hour. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether buprenorphine transdermal patches, 10 mcg/hour are medically necessary for the treatment of the patients medical condition. Scientists concluded, Buprenorphine is an atypical opioid that demonstrates efficacy similar to that of Schedule II full -opioid receptor agonists in managing chronic pain while exhibiting a favorable tolerability profile, including the reduced likelihood of abuse potential and respiratory depression. The authors also noted, Nonetheless, current clinical and long-term safety data support the use of buprenorphine over full -opioid receptor agonists for the effective and preferential treatment of chronic pain at a critical time when safer and less addictive treatments are needed. Studies reported, Buprenorphine may have safety advantages compared with full -opioid receptor agonists. Thus, it is recommended that buprenorphine be considered before Schedule II and perhaps Schedule IV opioids in patients with chronic pain and a favorable risk/benefit ratio for the drug on the basis of abuse potential, tolerability, and other factors. The authors also noted, In most patients receiving transdermal or buccal buprenorphine who are undergoing a surgical procedure or who have sustained traumatic injuries, buprenorphine should be continued in the perioperative/trauma period. In this case, the patient has chronic right shoulder pain. Imaging of the shoulder confirmed progressively worse glenohumeral joint arthritis. He has been treated with medications, including Norco, ibuprofen, acetaminophen and Celebrex in the past. He has also tried and failed several forms of conservative therapy. The provider noted that the treatment plan included weaning the patient off Norco and transitioning to buprenorphine patches. This strategy would lead to a significant decrease in the patients daily morphine milligram equivalents (MME), which were noted to be 40 MME. The medical evidence supports the requested medication in this clinical setting. Therefore, buprenorphine transdermal patches, 10 mcg/hour are medically necessary for the treatment of this patient. 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 anesthesiology 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.