Louisiana calls 90 MME a maximum. Its own policy proves it is not absolute.
Louisiana Medicaid permits approval above 90 MME and exempts specified diagnoses from the limit. The state should describe the number honestly as a clinical review threshold, require individualized reasons for denial, and stop treating physical dependence as though it were addiction.
The exception reveals the rule’s true function.
90 MME maximum
The posted Medicaid criteria describe cumulative opioid treatment as limited to a maximum of 90 MME per day.
Approval above it
The same system provides an override path when individualized criteria support treatment above the number.
Review threshold
Use accurate language, preserve utilization review, and require a patient specific reason for every adverse decision.
A number the state permits clinicians to exceed is not an absolute clinical maximum.
Separate the rule from the machinery enforcing it.
State rule and criteria
Louisiana law, administrative rules, and final Medicaid criteria establish the state level authority and terminology.
Claims control
Point of sale edits and prior authorization determine how the policy reaches a prescription at the counter.
Contractor implementation
Managed care plans and pharmacy benefit managers carry the state policy into separate operating systems.
Clinical guidance
CDC guidance informs risk review but does not itself compel Louisiana to call 90 MME a maximum.
Louisiana Medicaid owns the first correction.
Louisiana Department of Health and Louisiana Medicaid maintain the criteria, claims rules, and contractor requirements.
The Drug Utilization Review Board can examine predetermined utilization criteria and their effect on patient care.
The Pharmaceutical and Therapeutics Committee reviews drug classes and coverage recommendations when the subject is properly noticed.
Louisiana Revised Statutes section 49:964 allows an interested person to petition an agency for adoption, amendment, or repeal of a rule.
Legislative oversight becomes appropriate after the administrative record identifies a defect the Department will not correct.
Louisiana uses a maximum and an override at the same time.
The current narcotic analgesic materials state that cumulative daily MME for active opioid prescriptions is limited to 90 MME per day. Separate criteria allow requests to override the limit when the requested treatment is necessary and documented requirements are met.
The policy also provides categorical bypasses for specified claims, including cancer and palliative care circumstances. Those exceptions should be conceded accurately. They demonstrate that Louisiana already rejects universal application of the number.
The unresolved issue is the ordinary patient outside those categories. The state should preserve careful review without letting the number alone dictate denial or forced reduction.
Keep the review. Remove the fiction that one number is the patient.
Convert 90 MME from a maximum into a review threshold.
Rename
Replace “maximum” terminology with “individualized clinical review threshold” throughout Medicaid criteria and claims materials.
Protect
State that exceeding the threshold does not independently establish lack of medical necessity or require denial, tapering, or discontinuation.
Explain
Require an adverse decision to identify the patient specific clinical, coverage, or documentation reason beyond the MME number.
Distinguish
Separate expected physiological dependence and tolerance from addiction, misuse, diversion, and opioid use disorder.
A narrow correction that preserves review.
Proposed standard
A cumulative daily dosage of 90 morphine milligram equivalents is an individualized clinical review threshold and not an absolute dosage maximum. Exceeding the threshold does not, by itself, establish lack of medical necessity or require denial, reduction, or discontinuation. An adverse determination shall identify the patient specific clinical, coverage, or documentation basis for the decision. Physical dependence and tolerance shall not, without additional evidence, be treated as addiction, misuse, diversion, or opioid use disorder.
Formal request
Under Louisiana Revised Statutes section 49:964, please initiate the rule and policy changes necessary to apply this standard across fee for service Medicaid, managed care plans, pharmacy benefit managers, prior authorization criteria, and point of sale messaging. If the request is denied, provide written reasons within the statutory process.
Follow the rule from document to pharmacy counter.
Archive the operative documents. Preserve the current criteria, revision history, point of sale materials, rule text, public comment record, and contractor instructions.
File the rule request. Ask LDH to change the terminology, individualized decision standard, dependence language, and implementing systems.
Request the evidence. Seek the scientific basis, adoption record, override data, denial reasons, processing times, appeals, reversals, and contractor compliance records.
Use the DUR record. Ask the Drug Utilization Review Board to examine the 90 MME criterion as a predetermined utilization control.
Track formal rulemaking. Preserve notices, proposed text, comments, agency responses, oversight activity, final language, and effective dates.
Verify implementation. Test every managed care plan, benefit manager, fee for service pathway, and point of sale message against the final state standard.
Success must survive the claims system.
A policy change is incomplete until the patient can use it.
Prior authorization
The request form and reviewer instructions must treat the number as a trigger for evidence, not the reason for denial.
Point of sale
The pharmacy message must direct users toward review or override rather than communicate a universal clinical ceiling.
Stable continuation
Patients already benefiting from treatment need a practical renewal path that weighs function, risk, continuity, and documented response.
Managed care
A state standard that disappears inside contractor systems is not a completed reform. Each plan and benefit manager must be checked.
Escalate the record, not the temperature.
Give Louisiana Medicaid a complete, answerable rule and policy request with proposed language.
Use the DUR Board, public records, and formal comment opportunities to test the agency’s position.
Take a reasoned denial or incomplete rulemaking record to legislative oversight with a narrow correction.
Accept equivalent language if it accomplishes individualized review, accurate dependence terminology, reasoned decisions, and full implementation.
The purpose is correction, not authorship. Take the win when Louisiana accomplishes the substance.
Follow every claim to the document that controls it.
Say exactly what Louisiana does, and no more.
Confirmed
Louisiana Medicaid materials use a 90 MME maximum, categorical bypasses, and an override process for qualifying requests above the number.
Not established by policy text
The document alone does not prove that every above threshold request is denied or that every contractor applies the standard identically.
Method
Use aggregate records to measure approvals, denials, reversals, processing time, continuation outcomes, and contractor variation. Correct the Atlas when the record changes. This page provides public policy education, not medical or legal advice.
Call the threshold what it is.
Preserve serious review. Require serious reasons. Do not let a single number replace the patient.