Hydrocodone-acetaminophen 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 hydrocodone/acetaminophen 10/325 mg (Norco 90 tablets/30-day supply) and morphine sulfate extended-release tablets (90 tablets/30-day supply). The Centers for Disease Control and Prevention (CDC) reported, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days).Dowell and colleagues state, “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.” The Federation of State Medical Boards guidelines indicate that providers should use “opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective.” The guidelines recommend that providers “maintain opioid dosage a…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen (Norco) 10-325 mg, oral tablets, 180 count. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patient’s chronic pain. The submitted documentation does not support the medical necessity of the requested medication regimen. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The World Health Organization’s stepwise ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation submitted for review, there is a lack of objective towards treatment goals for pain and function for this patient. Several requirements for opioid prescribing have not been documented.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Hydrocodone-Acetaminophen (Norco) 10-325mg tablets, quantity of 120 tablets per month, taken as one (1) tablet by mouth every 6 hours as needed.Standard therapy for rheumatoid arthritis/psoriatic arthritis includes the use of biologic drugs and DMARDs which are immunosuppressive therapies and carry the risk for infection. Due to a history of the left knee prosthetic joint infection, the patient has chosen to avoid biologic drugs and other DMARDs and is currently on hydrocodone-acetaminophen, which is an opiate, a controlled substance, to control chronic joint pain.Opioid pain medication use presents serious risks, including overdose and opioid use disorder.

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 Hydrocodone-acetaminophen, then check the rights and deadlines that apply to your plan.