Oxycontin 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 Oxycontin. On determining when to initiate or continue opioids for chronic pain, researchers report, “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. If benefits do not outweigh risks of continued opioid therapy, 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.

Nature of Statutory Criteria/ Case Summary: The enrollee requested the medication, OxyContin. She has a history of lumbar spondylolisthesis that causes back and radiating leg pain rated as ten out of ten. Findings: The physician reviewer found that Her pain worsens with prolonged bending, standing, walking, coughing, and sneezing. She has taken narcotics and muscle relaxers, had physical therapy, chiropractic care, a spinal cord stimulator implantation, and steroids (both oral and epidural injections) for chronic pain. Spinal fusion surgery at the levels of L4-L5 and L5-S1 was performed. Post-operatively, a patient controlled anesthesia (PCA) pump with Dilaudid for pain management and physical therapy were provided. The enrollee had excessive pain and could only stand at the side of the bed for physical therapy, so she remained on the PCA pump.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Oxycontin and magnetic resonance imaging (MRI), spinal canal and contents, thoracic; without contrast for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Argoff and Silvershein note that for chronic non-cancer pain, short and long acting opioid has been found to be effective. “A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition.” Noting as well that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for an increase of Oxycontin from 15 milligrams (mg), two pills per day, to three pills per day for 30 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”.

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