Chronic Pain Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

A 52-year-old female enrollee has requested coverage for oxycodone liquid for treatment of the enrollee’s chronic pain syndrome, degenerative disc disease, and gastroesophageal reflux disease. Findings: The physician reviewer found that based on the records provided for review, the requested oxycodone liquid is medically necessary for this patient’s medical condition. The patient has a chronic pain condition due to degenerative joint disease of the spine. The patient also has severe digestive disease as documented by esophagogastroduodenoscopy and biopsy. The patient had multiple failed surgeries and tried several opioid medications without success. The patient displayed intolerance to oral medications as a result of her severe digestive disease.

A 29-year-old male has requested past and future coverage for 50 additional physical therapy (PT) sessions for the dates under review for treatment of his C7 spinal cord lesion. Findings: The physician reviewer found that based on review of the available records, this patient has a neuroenteric cyst at the C7 level which is causing his neck and bilateral shoulder and upper extremity pain. The patient’s right shoulder pain and weakness can be partially attributed to his shoulder pathology. His history is consistent with chronic pain syndrome, given the fact that his pain issues have persisted for more than three months. He is being treated by a psychiatrist for anxiety and depression, both of which are components of chronic pain syndrome. His providers documented that the patient is not a good surgical candidate at this time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate ER 45 mg two times daily. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollee’s chronic pain syndrome. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity in this clinical setting. The step wise World Health Organization ladder for pain relief is considered a reasonable approach for pain control in the palliative and the non-palliative setting. However, in the documentation available for review, there are no objective treatment goals for pain and function noted for the requested medication.

Nature of Statutory Criteria/Case Summary: a patient requested authorization and coverage for direct manipulation techniques during physical therapy. At issue in this case is whether the requested direct manipulation techniques during physical therapy are medically necessary to treat the enrollee’s medical condition.Ehlers Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic widespread pains and poor health-related quality of life. Generalized hyperalgesia has been reported, possibly due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia.

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 syndrome, then check the rights and deadlines that apply to your plan.