Actiq denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 26-year-old female with a history of chronic facial pain secondary to trigeminal neuralgia. The patient also has a diagnosis of fibromyalgia and has recently been diagnosed with Lambert-Eaton syndrome. She has been tried on numerous pain medications in the past including many narcotics. The patient experienced reactions such as rashes, pruritus, and even anaphylaxis to various narcotics tried. The patient is also unable to tolerate fentanyl patches secondary to sedation. She has been able to tolerate Actiq and therefore, has requested authorization and coverage for the medication.

The patient is a 36-year-old female with a history of migraines and cluster headaches since 1994, six months after delivery of her second child. The patient has been diagnosed with trigeminal neuralgia. She has been tried on numerous medications, acupressure, acupuncture, massage, and biofeedback, none of which have been effective. The only medication regimen that appears to have been effective is opiates. The patient is currently on Avinza as a baseline medication. She has requested authorization for Actiq for her breakthrough pain, which also causes nausea and vomiting, making oral medication regimens difficult. The Health Plan has determined that Actiq is not medically necessary for treatment of the patient’s pain.The patient has severe pain, which has failed to respond to conservative treatment.

Where the denial was upheld

The patient is a 37-year-old male with a working diagnosis of Familial Mediterranean Fever (FMF). His rheumatologist has understandably labeled this diagnosis as probable or presumptive at different times, though states that the diagnosis was confirmed under genetic screening. The physician’s notes include reference to extensive evaluation involving at least twelve physicians in various specialties, though genetic screening actually revealed heterozygosity for FMF, making its significance for the diagnosis uncertain. The submitted records describe rather unexpected continuous and unrelenting pain rather than the more usual episodic pain associated with FMF. Thus, it appears the patient has experienced repeated and ongoing failure of pain management.

The patient is a 43-year-old female with rheumatoid arthritis. The patient’s treatment regimen includes Remicade, Arava, prednisone, ibuprofen, and Excedrin. The patient has apparently had severe pain related to her rheumatoid arthritis and secondary degenerative joint disease, and recently underwent a hip replacement. The patient’s provider states the patient was given Actiq for breakthrough pain in association with her osteoarthritis prior to her hip replacement.The materials provided demonstrate the patient received an extensive array of narcotic medications in June, July and August 2004, including, oxycodone, OxyContin, Endocet and Kadian. Records from 8/31/04 indicate the patient was in no acute distress though she continued to take OxyContin 80mg three times daily. Included in the patient’s provider’s assessment were total body pain and chronic opioid therapy.

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