Chronic Fatigue Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for immune globulin therapy, Gammagard liquid 500 mg.Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), is a very difficult-to-diagnose disease. The most pronounced presentation is unexplained persistent severe fatigue. The authors of a study determined that there was a lower quality of life and a higher prevalence of fatigue among those with immunoglobulin subset deficiencies. Intravenous immunoglobulin therapy has been tried in patients with chronic fatigue syndrome and the consensus is that the therapy has resulted in significant benefit. Further, a recent study suggests that the benefit of intravenous immunoglobulin G (IV IgG) infusions to treat CFS/ME may have been underestimated.

The patient is a 53-year-old female with a history of chronic fatigue syndrome, fibromyalgia, obstructive sleep apnea, arthritis, and chronic headaches. She has been tried on all anti-inflammatories, Risperdal, Zonegran, Prozac, and Diazepam without benefit. The patient’s current medication regimen includes Welbutrin, Effexor, Fiorinal, Ambien, Soma, and Nortriptyline. She continues to have fatigue and constant pain. The patient also is participating in a chronic fatigue group. Her primary care physician has recommended Provigil to help improve the patient’s energy. The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patient’s medical condition. Based upon the submitted medical records, it does not appear the patient is currently responding to most of the medications that she has tried in the past.

Where the denial was upheld

Physician 1The patient is a 49-year-old woman diagnosed with chronic fatigue syndrome attributed to Epstein-Barr virus (EBV) infection. The submitted information does not provide corroborating historical or serologic evidence supporting the infection. The patient has a 30-year history of arthritis without documented deformity or synovitis. She currently experiences diffuse body aches including all joints with 15 minutes of morning stiffness. In addition, the patient has photosensitivity, Raynaud’s and alopecia. Her exam apparently revealed four tender points with no evidence of inflammatory arthritis or systemic lupus erythematosus (SLE) features. She has a low normal C4 with negative ANA, Ro, La dsDNA, normal ESR and CBC with an elevated parvovirus B-19 IgG and negative IgM. The patient has been treated with NSAIDS, narcotic analgesics, and anxiolytics.

The enrollee is requesting authorization and coverage for the treatment plan by provider, to include the medications: Valtrex (valacyclovir) 500mg three (3) times daily, Abilify (aripiprazole) 1.5mg daily, low-dose naltrexone 4.5mg daily, and Plaquenil (hydroxychloroquine) 300mg daily. The enrollee has chronic fatigue syndrome/myalgic encephalomyelitis/systemic exertion intolerance disease. She complains of profound fatigue, un-improved with bed rest and worsened by physical or mental activity. She has various non-specific symptoms, including weakness, muscle pain, impaired memory and/or mental concentration, insomnia, and post-exertional fatigue, lasting more than 24 hours. The enrollee has been on Valtrex, Plaquenil, Naltrexone, and Abilify.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving chronic fatigue syndrome, then check the rights and deadlines that apply to your plan.