Diagnosis: Breast Cancer
Treatment: Oxycontin (oxycodone ER)
The insurer denied: Oxycontin (oxycodone ER)
The determination is: Upheld.

The patient is a female with widely metastatic breast cancer. The patient has severe pain. The patient had a severe allergic reaction to morphine during which she experienced swelling and hives. The patient is currently receiving a regimen that includes OxyContin 20 milligrams (mg) every 8 hours; this is under review as a non-formulary drug.

The health plan's determination is upheld in whole.

This patient had an allergic reaction to morphine, and codeine is stated to also be contraindicated in this patient. However, this is not a contraindication to fentanyl, hydromorphone, methadone, or Nucynta. Further, it should be noted the patient is currently receiving Oxycontin. Extended-release oxycodone is the generic equivalent to this. There is no evidence that this patient would have an adverse outcome with these agents based on recommendations from the National Comprehensive Cancer Network (NCCN), the peer-reviewed literature, nor from the authors of UpToDate.