Oxycodone 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 oxycodone. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The most recent CDC guidelines 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.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Oxycodone three times/day. Per the medical records, standard practice assessments for misuse such as Controlled Substance Utilization Review and Evaluation System (CURES) monitoring and urine toxicology screenings are being performed. While opioids are not the first-line therapy for chronic pain syndromes, in this clinical setting of a patient with long-term pain with minimal to no relief from multiple prior surgeries, the requested medication is medically indicated. Therefore, Oxycodone three times/day is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet injections and/or oxycodone. With regard to the request for oxycodone, the Centers for Disease Control and Prevention (CDC) issued guidelines for the use of opioid medications in patients with non-cancer related pain for initiation, monitoring, and discontinuation. Specifically, the CDC guidelines state that opioids should only be considered when non-opioid and non-pharmacologic interventions have been ineffective, and when selected, should be used at the lowest dose that is effective and minimize opioid-related complications and risks including overdose. In addition, professional opioid management should include consultation to determine compliance as well as urine toxicology screening and an opioid use contract between the provider and the patient.

Findings: The physician reviewer found that The patient has requested authorization and coverage for Morphine Extended Release (ER) 15 mg tablets, two tabs taken every four hours (Quantity of 240 tablets every 30 days) and/or oxycodone 5 mg tablets, two tabs taken every four hours (Quantity of 240 tablets every 30 days). The updated 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.

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