Neuropathic Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxymorphone (Opana) 10 mg tablet, one every four hours for 12 months, and/or fentanyl patch 100 mcg, one patch every 72 hours for 12 months total. The updated Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy prescribing state that “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing the opioid dosage.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days).Dowell and colleagues state, “Non-pharmacologic therapy and non-opioid 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 non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.” The Federation of State Medical Boards guidelines indicate that providers should use “opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective.” The guidelines recommend that providers “maintain opioid dosage a…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast removal surgery for treatment of her breast pain and discomfort. Findings: The physician reviewer found that The request for breast removal surgery is not medically necessary for treatment of the patient’s medical condition. In this case, the patient does not have evidence of cancer in the reconstructed breast within the TRAM flap. Further, there is a lack of medical literature supporting the removal of TRAM flap reconstruction for chronic pain following the initial surgery. The pain that the patient experiences in the right chest appears to be neuropathic in nature. As noted by multiple providers, the requested breast removal procedure is not likely to alleviate the patient’s pain.

The patient has requested authorization and coverage for brand name Butrans patch (buprenorphine transdermal) 20 mcg/hour. This patient has severe neuropathic pain related to a complication from a lumbar sympathetic neurolysis procedure. He has been treated with numerous medications as well as interventional procedures to manage this pain. He has found that the Butrans patch has been the most beneficial pain relief modalities. Per the records, the patient was started on the brand name Butrans patch and subsequently switched to a generic formulation. He later reported to his provider that the generic patch was not as effective as the brand name Butrans patch. The U.S. Food and Drug Administration (FDA) reports that brand name and generic formulations are similar in every parameter.

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