Analgesics 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 methadone three times per day and Norco for treatment of the enrollee’s chronic pain due to fibromyalgia and cervical and lumbar radiculopathy. Findings: The physician reviewer has found based on the presented clinical records, the request for methadone and Norco are medically necessary for treatment of the patient’s medical condition. In this case, the patient presents with chronic nonmalignant pain. Her diagnoses include fibromyalgia and cervical and lumbar radiculopathy. Treatment with opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. There is evidence of failed treatments including non-medication management, interventional care, and non-opioid medications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections to the bilateral knees for treatment of her knee pain. Findings: The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Oxycontin for treatment of the enrollee’s chronic intractable pain syndrome. Findings: The physician reviewer found that based on the medical literature and the presented clinical records, Oxycontin 60 mg twice per day has not been established as medically necessary. The requested dosage and quantity are excessive in light of the patient’s condition and in addition to the medication regimen. Such doses and quantity are only indicated for malignant pain. The medical records shows the patient has chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation or joint disease is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections.

ature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin for treatment of her sarcoidosis. Findings: The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In this patient, the submitted records do not indicate that all non-opioid treatment options have been utilized nor does the documentation indicate an optimization of all non-opioid medications. Rather, quite large doses of opioids are being used despite research to show the dangers of a high dose and its lack of efficacy as it impacts quality of life. The submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use.

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