Norco 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 Norco 10/325 mg, five tablets per day.Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing for chronic pain state that 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. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day. On determining when to initiate or continue opioids for chronic pain, researchers report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) aqua therapy three times per week for eight weeks, (2) one-on-one physical therapy two times per week for eight weeks, (3) Norco (5 mg/325 mg tablets for 60 days), and (4) dexamethasone (4 mg tablets for 60 days).Findings: The physician reviewer found that Heywood and colleagues report that it is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for no tapering of Norco and/or magnetic resonance imaging (MRI) of the bilateral hips and knees. Per the American College of Radiology (ACR) recommendations, the requested MRI of the bilateral hips and knees is not medically necessary for evaluation of this patient. The ACR noted that, “Depending on history and physical examination, imaging may not be necessary to evaluate all hip pain” (Mintz, et al.). The ACR states that for chronic hip pain and low back, pelvic, or knee pathology where the goal is to exclude hip as the source, “radiographs negative, equivocal, or showing mild osteoarthritis.

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