Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen (Norco) 10-325 mg, oral tablets, 180 count. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic pain. The submitted documentation does not support the medical necessity of the requested medication regimen. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The World Health Organizations stepwise ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation submitted for review, there is a lack of objective towards treatment goals for pain and function for this patient. Several requirements for opioid prescribing have not been documented. The need to use opioids as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control guidelines state regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The Centers for Disease Control also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.  The Centers for Disease Control further states when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage. They should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than 50 to morphine milligram equivalents per day, and should avoid increasing dosage to greater than 90 morphine milligram equivalents per day or carefully justify a decision to titrate dosage to greater than 90 morphine milligram equivalents per day. In this case, the patient was recently taking 60 morphine milligram equivalents per day. Further, there was a lack of medical evidence-based rationale submitted by the provider, as well as the long-term consequences with the continual increase in opioids for this patient. A risk and benefit analysis must be done to justify the requested level of 60 morphine milligram equivalents per day. It is unclear what the plan was for the unseen future pain insults the patient could experience while on 60 morphine milligram equivalents per day. Studies show that simply increasing opioid and analgesic medications will alleviate symptoms in the short-term, resulting in dual saturation; however, down regulation will transpire, only to leave the patient back to where they started in terms of perception in pain. The patient will be worse off since they now have a much higher opioid tolerance level. The patient will require a much longer time to wean off the dual opioid/analgesic medications with even increasing the difficult process of resetting their pain receptors. Colleagues state that it is reasonable to consider alternatives to opioids with a plan to taper the patient to a lower dose of opioids or wean them off opioids altogether. Moreover, studies show that dual opioid/analgesic medications are not considered evidence-based treatments for fibromyalgia, not to mention the adverse effects in fibromyalgia patients specifically. In this patients case, not all non-opioid medications have been optimized or tried. For all these reasons, hydrocodone-acetaminophen (Norco) 10-325 mg, oral tablets, 180 count is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is 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-specialty in pain management 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.