Dilaudid denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving Dilaudidand overturned the plan’s denial in 8.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Dilaudid denials
| Category | Decisions | Overturned |
|---|---|---|
| Migraine | 3 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyFast 5 mg/5 mL (3,000 mL total), Dilaudid 8 mg (180 mg total), and Ketamine 150 mg/mL (60 mL total). This patient presents with a history of chronic pain related to CRPS and cyclic vomiting syndrome. He has attempted several forms of conservative non-opioid treatment modalities including plexus block injections, physical therapy, appendectomy, and cholecystectomy. The provider documented that the patient’s regimen of OxyFast, Dilaudid, and Ketamine has been managing his symptoms as a bridge to more sustainable treatment in the form of an intrathecal pain pump. The patient’s urine toxicology screens and Controlled Substance Utilization Evaluation System (CURES) reports have been consistent with therapy.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication regimen, Dilaudid four mg tablets taken as one tablet by mouth every four hours (quantity of 24 four mg tablets every 24 hours). In a systematic review and meta-analysis of opioid use for chronic non-cancer pain, researchers found that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. The authors noted that a comparison of opioid use with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality. The authors did not find that opioids were superior to non-opioid therapy for non-cancer pain.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dilaudid in a pill form. In a systematic review and meta-analysis of opioid use for chronic non-cancer pain, researchers found that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. The authors noted that a comparison of opioid use with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality. The authors did not find that opioids were superior to non-opioid therapy for non-cancer pain.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Dilaudid, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY