Percocet denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facet injections and Percocet 10mg (60 per 30 days). The current medical evidence does not support facet injections in this clinical setting. A randomized control trial regarding the use of facet joint blocks concluded that facet blocks are not therapeutic (Cohen, S., et al.). The trial also concluded that higher responder rates in certain treatment groups suggested that facet blocks might provide prognostic value before radiofrequency ablation. American Society of Interventional Pain Physicians (ASIPP) guidelines for interventional techniques in chronic spinal pain stated that the evidence for therapeutic lumbar facet joint blocks is weak.

Nature of Statutory Criteria/Case Summary: The patient has a medical history of cervical stenosis with myelopathy, lumbar stenosis with myelopathy, severe obesity, and osteoarthritis. He underwent a lumbar epidural steroid injection at L5-S1 in August 2017, and was evaluated by a neurosurgeon. He was advised to proceed with cervical surgery but he did not wish to proceed due to concern of worsening pain and disability after surgery. The provider indicated that cervical epidural steroid injection was not indicated due to stenosis, and the procedure might worsen symptoms. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spines showed moderate central canal stenosis at C3-4 with cord changes consistent with myelopathy, mild to moderate canal stenosis at T4-5, and moderate to severe canal stenosis at L3-L4.

Where the denial was upheld

Age: 60Gender: FNature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet medication, up to six pills per day/one pill every four hours, for a total of 168 pills for 28 days. 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a change in dosage of the medication Percocet 10/325 to 8-10 tablets a day.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that when opioids are started, clinicians should prescribe the lowest effective dosage. CDC guidelines state that clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to =50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to =90 MME/day or carefully justify a decision to titrate dosage to =90 MME/day. The guidelines also state that benefits of high-dose opioids for chronic pain are not established.

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