Soma 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 Xtampza, Percocet, and Soma. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines do not provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers “should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.” The Federation of State Medical Boards (FSMB) guidelines state “continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objecti…

Nature of Statutory Criteria/Case Summary: An enrollee has requested Soma and physical therapy for treatment of her medical condition. Findings: The physician reviewer found that the request for Soma is not medically necessary for treatment of the patient’s medical condition. Soma (carisoprodol) is indicated for acute, painful musculoskeletal conditions with noted side effects of drowsiness, dizziness, vertigo and ataxia. In addition, carisoprodol has been linked to dependence and in some states has been classified as schedule IV drug. Researchers performed a review which compared efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. The authors noted that efficacy was found to be poor for carisoprodol. In musculoskeletal conditions between relaxants, carisoprodol was poor and in comparison to placebo carisoprodol was also poor.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested morphine and Soma for treatment of his chronic pain. Findings: The physician reviewer found that the requested medications are not medically necessary. Such narcotics and at the doses prescribed is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially mask resolution of a preexisting pain condition.

A 51-year-old female enrollee has requested Soma for treatment of her chronic pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Soma is a muscle relaxant with more addictive and abusive properties than opioids. Additionally, Soma is a centrally acting muscle relaxant associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman).

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