Chronic Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for Belbuca films. In a meta-analysis and review of 33 studies looking at the use of buprenorphine in chronic pain, researchers concluded, “Buprenorphine is an atypical opioid that demonstrates efficacy similar to that of Schedule II full μ-opioid receptor agonists in managing chronic pain while exhibiting a favorable tolerability profile, including the reduced likelihood of abuse potential and respiratory depression.” Researchers report that consensus guidelines on the use of buprenorphine for chronic pain management recommend that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile based on metabolic factors, abuse potential, and tolerability, and that buprenorphine be continued during the perioperative/trauma period…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone bitartrate 20 mg extended-release capsule (one capsule every 12 hours). The submitted documentation supports the medical necessity of the requested medication. On determining when to initiate or continue opioids for chronic pain, researchers report, “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.

Where the denial was 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 patient’s 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 Organization’s 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Subutex. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee medical history.Findings: The documentation provided does not support the medical necessity for the requested medication in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings (Raffa and Pergolizzi). However, in the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. The Centers for Disease Control and Prevention (CDC) guideline states when opioids are started, providers should prescribe the lowest effective dosage.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving chronic pain, then check the rights and deadlines that apply to your plan.