Pain Medication denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Norco 10/325 tablets, two tablets three times a day (180 tablets per 30 days), (2) Valium 10 mg tablets, one to two tablets every night for sleep and one to two tablets every six hours as needed for anxiety (100 tablets for 30 days), and (3) additional Valium 10 mg (for a total dosage of Valium 20 mg) to be taken prior to magnetic resonance imaging (MRI) of the spine, one-time only. Findings: The physician reviewer found that this case, the patient has several diagnoses that contribute to her chronic pain condition and was placed on opioid analgesic therapy with a benzodiazepine.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta extended-release (ER) 12-hour 100 mg tablets. Baron and colleagues report in a review of five years of clinical data on the use of tapentadol (brand name Nucynta) prolonged release (PR) for chronic pain, “The clinical study program demonstrated effective and generally well-tolerated treatment for up to two years in a broad range of chronic pain conditions, including those with neuropathic pain components. This was confirmed in routine clinical practice observations.” The authors further noted, “Functionality, health status and quality of life also improved under tapentadol PR treatment. The gastrointestinal tolerability profile was more favorable compared to other tested World Health Organization (WHO) III opioids.

Where the denial was upheld

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication regimen, Dilaudid four mg tablets taken as one tablet by mouth every four hours (quantity of 24 four mg tablets every 24 hours). In a systematic review and meta-analysis of opioid use for chronic non-cancer pain, 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.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Pain Medicationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.