Lyrica denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for (1) brand-name Lyrica and (2) an additional four tablets of Nurtec ODT per 30 days.The records document a history of fibromyalgia and complex regional pain syndrome with neuropathic pain that has been effectively managed with brand-name pregabalin (Lyrica), allowing maintenance of function and continued employment. The records further document that treatment with generic pregabalin resulted in adverse effects, worsening headache, migraine symptoms, neck pain, back pain, and foot pain. Interruption of pregabalin therapy also resulted in severe pain and functional decline. Treating providers documented improved symptom control and tolerability with brand-name Lyrica compared with generic formulations.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 50 mg capsules, one capsule three times a day. Findings: The physician reviewer found that the patient’s pain can be described as a form of post-traumatic neuropathic pain. Physical examination confirms decreased sensation of the foot and loss of discrimination of sharp and dull touch. The patient has failed to respond to two different classes of neuropathic pain medications at therapeutic doses. Specifically, the patient was treated with gabapentin 300 mg three times a day, and Cymbalta 60 mg. The provider recommended to switch the patient to Lyrica in an attempt to provide better neuropathic pain control.

Where the denial was upheld

The patient is a 66-year-old male and has neuropathic symptoms of painful foot and leg tingling. Spinal stenosis has been diagnosed. Lumbar laminectomy has been performed in the past. The patient’s HbA1C was normal, but fasting glucose was elevated. No glucose tolerance test results are cited. A podiatry evaluation for plantar fasciitis resulted in a diagnosis of neuropathic symptoms “apparently from the back.” NSAIDs, Neurontin, physical therapy, and spinal injections were tried without sustained relief. Recently, the patient received a trial of Lyrica. The patient and his provider indicate Lyrica has completely controlled his symptoms. At issue is whether Lyrica is medically necessary for treatment of the patient’s medical condition.The patient has symptoms suggesting polyneuropathy. Etiologic diagnosis is unclear.

The patient is a 45-year-old female with neuropathic pain in her feet and a clinical diagnosis of tarsal tunnel syndrome has been made. The record did not include evidence of electro-diagnostic testing to confirm or disprove a diagnosis of polyneuropathy versus focal entrapment neuropathies. The patient is said to have failed treatment with Neurontin at an unspecified dosage and it is not noted whether she failed due to side-effects or lack of benefit at the maximal dosage. The patient appears to be tolerating Lyrica and indicates a benefit in reduction of pain symptoms. The patient’s provider indicates there is less than complete relief of the patient’s symptoms with Lyrica, and other than Neurontin, there is no indication other medications have been utilized for treatment of the patient’s peripheral neuropathic pain.

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