Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone/acetaminophen 10/325 mg (Norco 90 tablets/30-day supply) and morphine sulfate extended-release tablets (90 tablets/30-day supply). The Centers for Disease Control and Prevention (CDC) reported, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The CDC also noted, Because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days, limiting days of opioids prescribed also should minimize the need to taper opioids to prevent distressing or unpleasant withdrawal symptoms. In this case, the patient has chronic low back pain despite two failed back surgeries, injection therapy, physical therapy, TENS unit therapy as well as medication management. Currently, he is on high dose opioid therapy, with 40% (9 to 5 on pain scale) improvement in pain and functionality. The current guidelines recommend that patients that are on chronic opioid therapy for non-cancer pain be on the lowest dose possible in combination with non-pharmacologic treatments. They also suggest that patients demonstrate significant improvements in pain relief and functionality when on chronic opioids. Consideration should be given in patients on high dose opioids to supervised tapering to the lowest effective dose, particularly if the medication has less than desired effectiveness and is associated with opioid related complications. Abrupt discontinuation of high dose opioid therapy is not recommended by the CDC guidelines due to concerns for severe withdrawal symptoms. The medical evidence supports tapering the requested medications in this clinical setting, and a discussion with the treating provider regarding tapering is appropriate. Therefore, the requested medications are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications are 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.