Oxycodone-acetaminophen denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply), and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply. The Washington Agency Medical Directors’ Group guidance on prescribing opioids postoperatively recommends prescribing the lowest effective dose strength in cases of severe pain for 14 days or less. The authors note that for exceptional cases warranting more than 14 days of opioid treatment, the surgeon should reevaluate the patient before refilling the prescription and taper the patient off opioids within six weeks after surgery. On determining when to initiate or continue opioids for chronic pain, researchers report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen #96 tablets per 30-day period. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, “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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication regimen, oxycodone/acetaminophen (Percocet) one to two tablets every six to eight hours as needed. Researchers found that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. The authors noted that a comparison of opioid use with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality. The authors did not find that opioids were superior to non-opioid therapy for non-cancer pain.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen 10-325 mg (#120 tablets per 30 days, one tablet every six hours as needed with six refills). The submitted documentation does not support the medical necessity of the requested medication. Manchikanti and colleagues state, “To establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations if necessary.

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