Diagnosis: Severe Spinal Stenosis

Treatment: Oxycodone 5 mg tablet (1-2 tablets every 6 hours as needed for a total of 180 tablets)

The insurer denied Oxycodone 5 mg tablet (1-2 tablets every 6 hours as needed for a total of 180 tablets). The denial was reversed.

This is a female patient who suffers from severe spinal stenosis and has a history of sciatica, obstructive sleep apnea, depression, carotid artery stenosis, hypertension, chronic obstructive pulmonary disease, hypercholesterolemia, osteoarthritis, tendonitis, fibromyositis, alcohol abuse, status post cervical spine surgery, status post laminectomy, status post foot drop surgery, and status post C3-4 anterior cervical discectomy and fusion. It was reported that the patient suffers from chronic pain and had been on a stable dose of a narcotic for the past several years. She has had serial urine drug testing, all of which have been normal. A request was made for continued medication to manage his pain.

Dowell et al.(1) have commented on the misapplication of the CDC guideline, which has led to decisions like this one by the Health Plan (HP). "Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with and often go beyond, its recommendations. A consensus panel has highlighted these inconsistencies, five which include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician's practice . . . patients may find tapering challenging; could face risks related to withdrawal symptoms, increased pain, or unrecognized opioid use disorder; and if their dosages are abruptly tapered may seek other sources of opioids or have adverse psychological and physical outcomes. Policies should allow clinicians to account for each patient's unique circumstances in making clinical decisions."

Kroenke et al.(2) similarly, have supported the continuation of opiates at lower levels in patients who are stable, functional and show no signs of abuse.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for Oxycodone 5 mg tablet (1-2 tablets every 6 hours as needed for a total of 180 tablets) is reversed. The medical necessity is substantiated.