Buprenorphine 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 buprenorphine (Butrans Patch 5 mcg). Researchers performed a meta-analysis comparing the results of 33 studies evaluating the safety and efficacy of buprenorphine in the treatment of patients with chronic pain. The authors concluded that the “current clinical and long-term safety data support the use of buprenorphine over full mu-opioid receptor agonists for the effective and preferential treatment of chronic pain at a critical time when safer and less addictive treatments are needed.” In this case, the patient has chronic neck pain with radicular features and cervical canal stenosis at C5-6 and C6-7 confirmed on magnetic resonance imaging (MRI). She has tried and failed multiple conservative treatment options.

The patient is a 42-year-old man with a history of chronic neck pain and sleep disorder. The patient’s chronic neck pain secondary to degenerative disc disease status post laminectomy and fusion has been treated with pain medications including hydrocodone, Oxycontin, Methadone, and Percocet. The patient was subsequently weaned off all opiates. In October 2001, the patient was started on buprenorphine, which adequately managed his pain. The patient also had increasing symptoms of sleep disorder for which he was tried on benzodiazepines, Ambien, anti-epileptic drugs, tricyclics, chlorhydrate, phenobarbital, and antihistamines. However, the medications used either had significant side effects or did not have any effect on his sleep. The patient was started on Xyrem in August 2003, which improved the patient’s sleep disorder thus allowing him to be more functional.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Buprenorphine for treatment of his chronic back pain. Findings: The physician reviewer found that in this patient’s case, the requested Buprenorphine is not medically necessary for treatment of his medical condition. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for buprenorphine for treatment of the enrollee, who has a history of lower back pain. Findings: The physician reviewer found that the documentation provided does not support the medical necessity of the requested buprenorphine in this clinical setting. The records do not mention counseling, despite research and recommendations to support its use in opioid dependency and abuse. Moreover, the notes state he is taking methadone, Percocet, and buprenorphine. There is no clear objective functional goals for the additional buprenorphine being requested. Buprenorphine is only U.S. Food and Drug administration approved and indicated for opioid dependence. However, it is unclear why Suboxone is not sufficient for this patient, given the history, per the provider, of abusing opioids.

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