Vicodin denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving Vicodinand overturned the plan’s denial in 5.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Vicodin denials
| Category | Decisions | Overturned |
|---|---|---|
| Chronic Pain | 3 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, Vicodin, 5/300mg for a quantity of 30 tablets. The enrollee has a history of chronic low back and neck pain. X-rays of the neck showed disc degeneration, while a magnetic resonance imaging (MRI) of the neck showed slight progression of degenerative changes that are causing neuroforaminal narrowing from C3-4 to C5-6; and mild spinal stenosis at C4-5. The enrollee underwent right cervical medial branch blocks and had 80% improvement of the pain. He will have radio-frequency ablation. He has seen a pain management physician and has tried anti-inflammatories, muscle relaxants, physical therapy, acupuncture, cervical branch block injections, and a home exercise program.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vicodin. Findings: The physician reviewer found that the available records document that this patient presents with chronic migraine headaches. The provider noted that the patient has been treated with medication management including preventative medications without adequate relief. Additional treatment with Botox therapy yielded some benefit. The patient’s provider has advised that nortriptyline could be considered in the future if needed. The patient has requested treatment with Vicodin. The patient’s providers have not recommended treatment with Vicodin. The current guidelines and studies do not support that opioid therapy provides long-term benefit for patients with chronic migraine.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vicodin 5 mg to be taken twice daily. 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. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” The guidelines further advise, “Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Vicodin, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY