Morphine denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 15 mg, four times per day for treatment of his chronic pain. Findings: The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) guidelines suggest that chronic opiate maintenance is associated with elevated risks. The CDC also indicate that a consultation with pain management is necessary before tapering the patient. The general approach is to taper 10% per week while replacing the opiate with another non-narcotic pain therapy. The patient was treated with morphine 15 mg with a total dose of 60 mg. His morphine prescription has been cut in half. A 50% reduction is not a gradual taper. He is currently on a sub therapeutic dose of gabapentin.

A 46-year-old female enrollee has requested for continued use of morphine for treatment of her multiple sclerosis and degenerative joint disease (DJD). Findings: The physician reviewer found that the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) states that, “for a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.”

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested morphine and Soma for treatment of his chronic pain. Findings: The physician reviewer found that the requested medications are not medically necessary. Such narcotics and at the doses prescribed is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially mask resolution of a preexisting pain condition.

Nature of Statutory Criteria/Case Summary: The patient is a 66-year-old female who was diagnosed with fibromyalgia, cervical spondylosis, and chronic pain syndrome is requesting authorization and coverage for morphine. Findings: The physician reviewer found that e patient’s sensation, strength, and reflexes were reported to be intact. The patient’s provider noted that the patient was involved in a car accident due to falling asleep while driving. The provider noted safety concerns for the patient and recommended tapering off morphine. A pain management specialist did not recommend opioids for the patient’s chronic pain and agreed with the plan to taper off opioid medications. Non-opioid therapy was recommended to treat the patient’s fibromyalgia. At issue in this case is whether morphine is medically necessary for treatment of this patient’s medical condition.

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