Pinnacol Assurance is focused on providing the best care for injured workers by promoting guidelines related to the appropriate use of opioids. Pinnacol Assurance will not authorize payment for subacute and chronic opioid prescriptions unless the prescriber explains the reasonableness and the medical necessity and provides relevant supporting medical documentation.
Prescribing opioids beyond the initial fill
Opioids prescribed beyond an initial 14-day amount require a prior authorization request (Rule 16-11(C)(1)). The request should include all clinic notes to date not yet been submitted to Pinnacol, and in meaningful and specific detail should address the following:
- Has the patient failed an adequate trial of acetaminophen, aspirin and/or NSAIDS, as well as medications specific for neuropathic pain (if applicable)? What was the duration and dosing of these medications?
- Have you formally assessed the patient’s risk factors for opioid addiction? What are the detailed results?
- Has the patient used opioids within 3 months of his or her injury? If so, provide detail about the specific drug(s), dosing, and duration of use.
- Is the patient currently using benzodiazepines, alcohol, or muscle relaxants? If so, provide detail and clinical justification for prescribing an opioid.
- Summarize the date and results of a recent PDMP check.
- Is the patient in a “safety sensitive position” (e.g., driving is a job requirement)?
- Is there a reasonable likelihood that you will prescribe opioids for longer than 30 days?
Upon receipt of the above-requested information a nurse advisor may approve payment for an additional one to two weeks of opioids. The submission of insufficient documentation and/or an independent expert review may result in denial of payment for additional opioids.
Prescribing opioids beyond 30 days
Prior authorization for payment must be requested by the provider when a prescribed service exceeds the recommended limitations set forth in the Medical Treatment Guidelines (Rule 16-10(B)(1). The request should include all clinic notes to date not yet been submitted to Pinnacol, and in meaningful and specific detail, please address the following:
- A description of and clinical rationale for the proposed pain-management regimen.
- The results of a physical and psychological and/or psychiatric assessment including a full evaluation for alcohol or drug addiction, dependence or abuse, performed by two specialists including the authorized treating physician and a physician or psychologist specialist with expertise in chronic pain.
- A description of the multi-disciplinary pain management program in which the patient has been enrolled.
- A copy of a newly executed narcotic contract between the prescribing provider and the patient.
- Agreement to immediately complete (or clinical rationale for not completing) a 30-day short-acting opioid trial involving follow-up every two to four weeks that assesses functional ability that is specific, quantitatively measurable and relevant (e.g. return-to-work, activities of daily living). The agreement should include a provision to taper and discontinue opioids if there is no meaningful functional improvement and sustained reduction in pain of at least 30% (Rule 17, Exhibit 9, pp. 101-102).
- A copy of urine drug testing results obtained within the past month and prior to initiating the opioid trial.
- A patient-signed copy of a shared decision-making agreement that addresses the risks and benefits of opioid therapy.
Upon receipt of the information, a nurse advisor may approve payment for an additional 4 weeks of opioids for a therapeutic opioid trial to be completed. The submission of insufficient documentation and/or an independent expert review may result in denial of payment for additional opioids.
If you anticipate prescribing opioids beyond the period of the opioid trial, please provide a summary of the trial results after it is completed.
This protocol is not intended in any way to direct the type or duration of medical treatment that may be prescribed. We understand that you must exercise your independent medical judgment in these matters.