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California - Lifetime Med - Coverage Terminated
I will give an example of how I did internal UR appeals or your doctor can incorporate this in his request. Not all carriers have an internal UR appeal process, but most do.

UR denial #
UR denial date:
Injured worker name:
Injured worker claim number:

RE:Internal UR appeal

Dear ----

I am requesting an internal UR appeal for denial of Lidoderm patches. UR physician denied request based upon (insert guideline used). This guideline does not fit my complex condition of failed back surgery syndrome including (list other conditions affecting back for example fibromyalgia, scar tissue, nerve pain etc). Due to this I am useing a guideline outside of MTUS and instead using guideline for Lidoderm patch under Medical Mutual for Lidoderm patch. This medical treatment guideline is more appropriate for my condition and MTUS, (or guideline used to deny Lidoderm patches) is silent on my complex condition.


Lidocaine 5% patch is an amide-type local anesthetic agent whose neuronal membrane stabilizing effect produces a local analgesic effect when applied transdermally. The lidocaine penetration into intact skin is adequate to produce an analgesic effect, but less than the amount needed to produce a complete sensory block.

Coverage of lidocaine 5% patch is recommended in those who meet the following criteria: Food and Drug Administration (FDA)-Approved Indications 1. Postherpetic Neuralgia (PHN). Approve. Other Uses with Supportive Evidence 1. Low Back Pain. Approve after trying at least three prescription pharmacologic therapies with each one from a different class of medication used to treat low back pain (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] {e.g., etodolac, meloxicam, nambutone}, muscle relaxants (e.g., carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine), opioids, celecoxib, tramadol, gabapentin, tricyclic antidepressants [TCAs] {e.g., amitriptyline, desimpramine, imipramine, nortriptyline}). 2. Neuropathic Pain (not Sciatica). Approve. 3. Osteoarthritis (OA). Approve after trying at least three prescription pharmacologic therapies with each one from a different class of medication used for the treatment of OA of the hand, hip, and knee (e.g., celecoxib, nonsteroidal anti-inflammatory drugs [NSAIDs] {e.g., etodolac, meloxicam, nambutone}, salicylates, tramadol, opioids, intraarticular glucocorticoids, intraarticular hyaluronan, topical capsaicin, and topical methylsalicylate).

Lidoderm® patches [prescribing information]. Chadds Ford, PA: Endo Pharmaceuticals, Inc.; January 2015. 2. White WT, Patel N, Drass M, Nalamachu S. Lidocaine patch 5% with systemic analgesics such as gabapentin: a rational polypharmacy approach for the treatment of chronic pain. Pain Med. 2003;4(4):321-30. 3. Galer BS, Gammaitoni AR, Oleka N, Jensen MP, Argoff CE. Use of the lidocaine patch 5% in reducing intensity of various pain qualities reported by patients with low-back pain. Curr Med Res Opin. 2004;20(Suppl 2):S5-12. 4. Gimbel J, Linn R, Hale M, Nicholson B. Lidocaine patch treatment in patients with low back pain: results of an open-label, nonrandomized pilot study. Am J Ther. 2005;12:311-319. 5. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491. 6. Barbano RL, Herrmann DN, Hart-Gouleau S, Pennella-Vaughan J, Lodewick PA, Dworkin RH. Effectiveness, tolerability, and impact on quality of life of the 5% lidocaine patch in diabetic polynneuropathy. Arch Neurol. 2004;61(6):914-918.
7. Micromedex® Solutions. Truven Health Analytics Inc. Available at: http://www.micromedexsolutions.com/home/dispatch. Accessed on August 7, 2015. Search terms: lidocaine. 8. Meier T, Wasner G, Faust M, et al. Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study. Pain. 2003;106(1-2):151-158. 9. Galer BS, Jensen MP, Ma T, et al. The lidocaine patch 5% effectively treats all neuropathic pain qualities: results of a randomized, double-blind, vehicle-controlled, three-week efficacy study with use of the neuropathic pain scale. Clin J Pain. 2002;18:297-301. 10. Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open-label study. Clin J Pain. 2000;16:205-208. 11. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol. 2003;60(11):1524-1534. 12. Herrmann DN, Barbano RL, Hart-Gouleau S, et al. An open-label study of the lidocaine patch 5% in painful idiopathic sensory polyneuropathy. Am Acad Pain Med. 2005;6(5):379-384. 13. Fleming JA, O’Connor BD. Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre. Pain Res Manage. 2009;14:381-388. 14. Bril V, England J, Franklin GM, et al. Evidence-based Guideline: Treatment of Painful Diabetic Neuropathy Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011;76(20):1758-1765. 15. Dworkin RH, O’Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. 2010;85:S3-S14. 16. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64:465-474. Available at: http://www.guideline.gov/content.aspx?id=36893. Accessed on August 7, 2015. 17. Galer BS, Sheldon E, Patel N, et al. Topical lidocaine patch 5% may target a novel underlying pain mechanism in osteoarthritis. Curr Med Res Opin. 2004;20(9):1455-1458. 18. Gammaitoni AR, Galer BS, Onawala R, et al. Lidocaine patch 5% and its positive impact on pain qualities in osteoarthritis: results of a pilot 2-week, open-label study using the Neuropathic Pain Scale. Curr Med Res Opin. 2004;20(Suppl 2):S13-19. 19. Burch F, Codding C, Patel N, Sheldon E. Lidocaine patch 5% improves pain, stiffness, and physical function in osteoarthritis pain patients. Osteoarthritis Cartilage. 2004;12(3):253-255. 20. Stitik TP, Altschuler E, Foye PM. Pharmacotherapy of osteoarthritis. Am J Phys Med Rehabil. 2006;85(11 Suppl):S15-S28. 21. Kivitz A, Fairfax M, Sheldon EA, et al. Comparison of the effectiveness and tolerability of lidocaine patch 5% versus celecoxib for osteoarthritis-related knee pain: post hoc analysis of a 12-week, prospective, randomized, active-controlled, open-label, parallel-group trial in adults. Clin Ther. 2008;30:2366-2377. 22. Nalamachu S, Crockett RS, Mathur D. Lidocaine patch 5 for carpal tunnel syndrome: how it compared with injections: a pilot study. J Fam Pract. 2006;55(3):209-214. 23. Nalamachu S, Crockett RS, Gammaitoni AR, Gould EM. A comparison of the lidocaine patch 5% vs. naproxen 500 mg twice daily for the relief of pain associated with carpal tunnel syndrome: a 6-week, randomized, parallel-group study. MedGenMed. 2006;8(3):33. 24. American Academy of Orthopaedic Surgeons. Clinical practice guideline on the treatment of carpal tunnel syndrome. September 2008. Available at: http://www.aaos.org/research/guidelines/...tguide.asp. Accessed on August 7, 2015. 25. Dalpiaz AS, Lordon SP, Lipman AG. Topical lidocaine patch therapy for myofascial pain. J Pain Palliat Care Pharmacother. 2004;18(3):15-34. 26. Firmani M, Miralles R, Casassus R. Effect of lidocaine patches on upper trapezius EMG activity and pain intensity in patients with myofascial trigger points: a randomized clinical study. Acta Odontol Scand. 2015;73(3):210-218. 27. Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo path, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. 2009;31:705-720. 28. Lin YC, Kuan TS, Hsieh PC, et al. Therapeutic effects of lidocaine patch on myofascial pain syndrome of the upper trapezius: a randomized, double-blind, placebo-controlled study. Am J Phys Med Rehabil. 2012;91:871-882. 29. Ingalls NK, Horton ZA, Bettendorf M, et al. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. 2010;210:205-209. 30. Zink KA, Mayberry JC, Peck EG, et al. Lidocaine patches reduce pain in trauma patients with rib fractures. Am Surg. 2011;77(4):438-442.

As per (insert guideline) I have attempted (insert what you have attempted mentioned in the guideline ) first and have not gotten relief. I am also attempting to ween myself to lower opioids and need alternative treatment for pain relief. MTUS is also silent on this issue.

Please see attached medical re[ports stating my conditions and relevant info.

(list date and name of doctor report

1. Dr Smith report on (date)
2. UR denial of pain medication dated



I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

Messages In This Thread
RE: California - Lifetime Med - Coverage Terminated - California_Help - 02-19-2019, 02:57 PM

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