Fibromyalgia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services ASAM Level 3.5. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient underwent management for opioid withdrawal and medication assisted treatment with suboxone. The patient’s withdrawal needs were safely managed in a Level 3.5 setting.

Physician 1The patient is a 58-year-old woman with a history of fibromyalgia with associated chronic fatigue syndrome and depression since the early 1990’s. The patient has been prescribed many medications including Trazadone, Nortriptyline, Flexeril, Celexa, Zoloft, Ultram, Voltaren, etodolac, and Neurontin. Treatment with these medications provided the patient with significant pain relief but resulted in minimal increase in her energy level. Since initiating Provigil in June 2003 the patient has noted marked improvement in her energy level and quality of life. She has also been able to stop use of Neurontin while taking Provigil. The patient has requested authorization and coverage for continued treatment with Provigil.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for the requested medication, Belbuca (600Mcg film, 60 per month).The Medical Board of California’s Guidelines for Prescribing Controlled Substances for Pain state that continuation, modification or termination of opioid therapy for pain should be contingent on the provider’s evaluation of evidence of the patient’s progress toward treatment objectives and the absence of substantial risks or adverse events. The guidelines recommend that providers consider the “5-As” method for chronic pain management assessment.

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.

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