CurrentUniversity Health Alliance (HSA)Policy MPP-0080-120515

Chronic Opioid Therapy (COT) reimbursement and monitoring for non‑cancer pain

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Defines medical necessity criteria, documentation, and administrative rules for reimbursement of chronic opioid therapy for non-cancer pain under University Health Alliance (UHA). Affects providers prescribing long-term opioids to UHA members.

Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyChronic Opioid Therapy (COT) reimbursement and monitoring for non‑cancer pain

Policy CodePolicy MPP-0080-120515

Change TypeNo material changes

Effective DateAug 1, 2022

Last ReviewAug 1, 2022

Next Review Date

Key ActionDocument medical necessity and monitoring (history, exam, risk assessment, informed consent, treatment agreement, PDMP review, and UDS) in the medical record and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥50 MME/daydosage threshold triggering additional precautions

≥90 MME/daydosage generally to avoid/increased risk

>3 monthsduration defining chronic pain

annually

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CurrentUniversity Health Alliance (HSA)Policy MPP-0080-120515

Chronic Opioid Therapy (COT) reimbursement and monitoring for non‑cancer pain

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Sign up for University Health Alliance (HSA) Policy MPP-0080-120515 alerts

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Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyChronic Opioid Therapy (COT) reimbursement and monitoring for non‑cancer pain

Policy CodePolicy MPP-0080-120515

Change TypeNo material changes

Effective DateAug 1, 2022

Last ReviewAug 1, 2022

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥50 MME/daydosage threshold triggering additional precautions

≥90 MME/daydosage generally to avoid/increased risk

>3 monthsduration defining chronic pain

annually

Medical Necessity & Monitoring Criteria

Medical necessity and monitoring criteria for COT

COT is covered when medically necessary and when ALL of the following initiation, monitoring, and follow‑up requirements are met:

ALL of the following

Pre‑initiation requirements
- Expected benefits for both pain and function are anticipated to outweigh risks to the patient.
- Opioids are not first‑line or routine therapy for chronic pain outside of active cancer, palliative, or end‑of‑life care; nonpharmacologic therapies (e.g., exercise therapy, CBT) should be used to reduce pain and improve function.
- Nonopioid pharmacologic therapies should be used when benefits outweigh risks and combined with nonpharmacologic therapy as appropriate.
- Clinician completes history, physical exam, and appropriate testing including assessment of risk of substance abuse, misuse, or addiction (risk stratification may use ORT, CAGE‑AID, PHQ‑9, SOAPP‑R, or PADT).
- Discuss risk mitigation strategies with patient, including offering naloxone when risk factors for overdose are present.
- Obtain informed consent and a treatment agreement prior to prescribing a supply of 30 days or greater (treat initial opioid therapy as a therapeutic trial).
- Review the patient’s controlled substance prescription history via the Hawaii PDMP (PMP AWARxE) prior to initiation and periodically during therapy (hawaii.pmpaware.net).
Initiation and dosing
- Use immediate‑release opioids for initial therapy; reserve extended‑release/long‑acting formulations for severe, continuous pain or after at least 1 week of daily immediate‑release use.
- Start at the lowest effective dose and individualize selection, initial dosing, and titration according to health status, prior opioid exposure, therapeutic goals, and observed harms.
- Exercise caution at or above 50 MME/day and generally avoid doses at or above 90 MME/day.
Monitoring
- Obtain urine drug screening (UDS) before starting opioid therapy and consider UDS at least annually to assess for prescribed medications and other controlled or illicit drugs; follow UHA UDS policy to avoid undue patient financial burden.
- Evaluate benefits and harms within 1–4 weeks of initiation or dose escalation, then reassess every 3 months (or more frequently) documenting pain intensity, function, progress toward goals, adverse events, and adherence to prescribed therapies.
- Identify local treatment resources for pain management and opioid use disorder and consider consultation with psychiatry, neurology, addiction medicine, PM&R, or pain medicine when indicated (see consultation triggers).
Triggers for specialty consultation or mandated review
- ONE of
  - Ongoing pain without improvement in function despite opioid treatment.
  - Preexisting psychiatric diagnosis or new mood/anxiety/psychotic symptoms, current psychiatric medications, or history of substance abuse.
  - Patient requests more than 90 mg MED (morphine equivalent dose) daily.
Discontinuation and tapering
- Consider discontinuation if any of the following
  - No documented improvement in pain level or function in a patient compliant with COT.
  - Opioid therapy produces significant adverse effects.
  - Patient exhibits drug‑seeking behaviors or diversion (e.g., selling/forging prescriptions, aggressive demands, unsanctioned use, multiple prescribers/ER visits, or failing UDS defined as absence of prescribed drug or presence of nonprescribed opioids).
- If therapy is discontinued, taper cautiously per current practice guidelines and counsel patients on increased overdose risk if they return abruptly to higher prior doses.

Dosage Thresholds and Coding Notes

MME thresholdsmixed

50 MME/day	Caution threshold: providers should regard doses at or above this level as higher risk for overdose and exercise caution.
90 MME/day	Dose generally to avoid: providers should generally avoid dosing at or above this level due to increased risk.

inv-03: Caution threshold

Caution threshold50 MME/day

Action when at/above thresholdExercise caution and reassess benefits vs risks; consider increased monitoring and risk mitigation (e.g., naloxone, more frequent follow-up)

DocumentationDocument justification for doses approaching threshold and rationale for continued therapy in the medical record

inv-04: Avoid generally

Avoid generally threshold90 MME/day

When requested >90 MED/dayConsider mandating specialty consultation and use equianalgesic tables/online calculators to confirm MED

Authorization, Documentation, and Administrative Rules

Prior Authorization

Prior authorization not required; check pharmacy benefit restrictions

Prior authorization is not required for chronic opioid therapy under this payment policy; however, providers should be aware that pharmacy benefit restrictions on long‑term opioids are managed by UHA's pharmacy benefits manager and may apply.

Documentation Required

Document medical necessity and expect retrospective review

Maintain legible documentation of medical necessity in the patient medical record and make it available to UHA upon request; UHA may perform retrospective review to validate services against the policy criteria and payment determination.

Documentation must be legible and maintained in the patient's medical record.
UHA reserves the right to request records and to perform retrospective review to validate medical necessity and correct reimbursement.

Key Definitions

inv-07: Chronic pain

DefinitionChronic pain: pain that typically lasts >3 months or past the time of normal tissue healing; may result from disease, injury, treatment, inflammation, or unknown causes

ExclusionsLimitations in this policy do not apply to active cancer, palliative, or end-of-life opioid therapy

Policy expectationRequires ongoing evaluation and documentation when COT is employed

inv-08: Long-term opioid therapy

DefinitionLong-term opioid therapy: use of opioids on most days for >3 months

Initial approachTreat initial opioid therapy as a therapeutic trial with individualized selection, dosing, and titration; review PDMP prior to initiation

Exclusions and Noncovered Scenarios

This policy excludes certain care settings from the COT limitations: the limitations do not apply to active cancer, palliative, or end-of-life opioid therapy. UHA will reimburse for chronic opioid therapy for non‑cancer pain when it is medically necessary and meets the clinical criteria in this policy; however, the stated limitations and monitoring expectations are not intended to govern opioid therapy provided in the excluded settings cited above. (See policy identifiers and effective date in the policy history.)