Analgesic Rx denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and Diazepam for treatment of the enrollee’s chronic low back pain. Findings: The physician reviewer has found that based on the documentation submitted for review, the patient has had long-term opioid use and has been prescribed benzodiazepines medication on a long-term basis. He describes symptoms of withdrawal from both medications when unavailable. These medications have been prescribed as part of his care. Guidelines for opioid and benzodiazepine dependence recommend a slow taper when these medications are discontinued. In terms of Norco, a suggested taper is 10% every two to four weeks. In general, weaning of benzodiazepines such as diazepam takes more time than opioid withdrawal.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Embeda for treatment of her medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medical necessity for Embeda has been established in this clinical setting. Embeda has been noted to provide adequate analgesia without side effects and is comparable to Avinza. In addition, the patient is at low risk for opioid abuse, and she has tried and failed other morphine alternatives. Since Avinza was discontinued, she has tried and failed Kadian and two other MS Contin formulations. In addition, she has tried and failed fentanyl patch, Opana and Oxycodone. Embeda is a long acting morphine agent which has provided the patient with adequate pain relief.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco and valium for treatment of her diabetes type 2 with diabetic neuropathy and bilateral knee osteoarthritis. The physician reviewer found that review of the submitted documentation does not support the medical necessity of the requested medications Norco and valium. Cone and colleagues describes guidelines for opioid use that entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors including history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations…

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two 40mg OxyContin ER (extended release) per day and four 30mg oxycodone IR (immediate release) per day. Findings: The physician reviewer found that there is a lack of support for the medical necessity of the requested medications in this clinical setting. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patient’s case it is not entirely clear if the work up for the back pain has been finalized. In the documentation available for review, the magnetic resonance imaging has not been performed.

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