Pain Mgmt Prog denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an intensive inpatient pain management program for treatment of her fibromyalgia, fatigue and chronic headaches. The physician reviewer found that the request for an intensive inpatient pain management program is medically necessary for treatment of the patient’s medical condition. There is support for the requested services in the medical literature. The study by Angst and colleagues states “Intensive interdisciplinary rehabilitation with more behavioral therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay.” Angst and colleagues also stated that “Inpatient, structured interdisciplinary rehabilitation covering elements of cognitive and operant behavioral therapy, graded activity exercise, and adapted drug therapy r…

The patient is a 60-year-old female with a history of neck and shoulder pain, status post cervical fusion in 1995. She has been treated with multiple medical regimens such as non-steroidal anti-inflammatory drugs, cox II inhibitors, muscle relaxants, Lido-derm patches, steroid injections, physical therapy, acupuncture and chiropractic therapy without sustained pain relief. A pain management specialist evaluated the patient in March 2006 and noted neck pain radiating to bilateral upper extremities and a pain level of 5-7/10. Studies, including a CT discogram, revealed degeneration of the zygapophyseal joints at C2-3 on the right, C3-4 on the right and C4-5 on the right.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: a patient requested authorization and coverage for direct manipulation techniques during physical therapy. At issue in this case is whether the requested direct manipulation techniques during physical therapy are medically necessary to treat the enrollee’s medical condition.Ehlers Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic widespread pains and poor health-related quality of life. Generalized hyperalgesia has been reported, possibly due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture/acupressure, once per week, trigger point injections, medial branch blocks (MBBs), subacromial bursa injections, Percocet 10 mg, three times per day, oxycodone-acetaminophen 10-325 mg, every eight hours, pentoxifylline XR 400 mg, twice per day, Flexeril 10 mg, as needed, once per day, Neurontin 300 mg, three times per day, and Lyrica 50 mg, every 12 hours. Findings: The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services and requested medications. This patient has requested an array of therapies without proper clinical basis and against clinical practice guidelines. He has several red flags which make prescribing chronic opiates problematic.

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 Mgmt Progwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.