Methadone denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for methadone 10 mg five pills per day. The Health Plan has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollee’s chronic low back pain.The records indicate that this patient is being treated for chronic non-malignant pain. In terms of the patient’s medications, opioid medication can be considered as part of the standard of care when treating patients with chronic non-malignant pain. Concern for opioid misuse can result in undertreatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. The analgesic options for patients with chronic pain have steadily declined.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for methadone tablets with a quantity of 180 tablets every 30 days for chronic pain. Concerning this issue of whether clinicians should continue with opioid therapy for chronic pain, the Centers for Disease Control and Prevention (CDC) indicate that providers should carefully weigh the benefits and risks and exercise care when changing the opioid dosage. If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Methadone 5mg - 112 tablets every 28 days. The Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy prescribing state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy”. Further, the CDC advised that clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids so long as the benefits do not outweigh the risks of continued opioid therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone, four pills daily for treatment of the enrollee who has history of chronic back pain. Fulfills Findings: The physician reviewer found that the documentation provided does not support the requested medication quantity in this clinical setting. Several requirements for opioid prescribing have not been documented as performed. Objective treatment goals for pain and function are not noted for the requested medication and several recent requirements for opioid prescribing have not been documented. So, the need to use them as the primary medication treatment strategy for pain has not been established.

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