Diagnosis: Chronic Neuropathic Pain

Treatment: Monthly Quantity of 120 Oxycodone ER 80 mg tablets

The insurer denied the Monthly Quantity of 120 Oxycodone ER 80 mg tablets. The denial was reversed.

This is a female patient who has a history of cervical herniated disk (C5-C6), chronic neuropathic pain likely due to metronidazole neuropathy, migraines, mitral valve prolapse, adrenal insufficiency, Hashimoto thyroiditis, gastroesophageal reflux disease (GERD), rectal bleeding, vertigo, anal stenosis and spasm, and opioid dependence. Due to the patient's condition she suffers from chronic pain that requires 24 hour pain management. She has tried morphine and hydromorphone in the past; she was allergic. She has also tried non-steroidal anti-inflammatory (NSAIDS) which caused hematuria. It was noted that the patient has had good pain management on the current regimen; OxyContin ER 160mg and Fentanyl patch.

The patient has chronic pain due to neuropathy and cervical radiculopathy. She is able to work and function with round-the-clock pain medication, which she has taken for many years. The patient's neurologist notes that she has never abused or diverted medication. Suddenly discontinuing her pain medication is definitely not in the best interest of the patient. This patient has severe pain and pain control is medically necessary. Despite the current focus on curbing opiate abuse, there are many patients, including this one, who need opiates and do not abuse them. A JAMA editorial notes "The general philosophy regarding the level of attention that should be paid to pain, as well as its treatment, has changed dramatically during the past 30 years, swinging wildly between extremes, and remains a moving target.... Currently, most articles in the lay and even professional press highlight the problems associated with these drugs, as opposed to the significant benefits that may accrue from their appropriate use."1 This is a patient who would benefit significantly from appropriate use. She should be allowed to continue.

Based on the above, the medical necessity for the monthly quantity of 120 Oxycodone ER 80 mg tablets is substantiated. The insurer's denial is reversed.