Fatigue: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an intensive inpatient pain management program for treatment of her fibromyalgia, fatigue and chronic headaches. The physician reviewer found that the request for an intensive inpatient pain management program is medically necessary for treatment of the patient’s medical condition. There is support for the requested services in the medical literature. The study by Angst and colleagues states “Intensive interdisciplinary rehabilitation with more behavioral therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay.” Angst and colleagues also stated that “Inpatient, structured interdisciplinary rehabilitation covering elements of cognitive and operant behavioral therapy, graded activity exercise, and adapted drug therapy r…

The patient is a 53-year-old female who is requesting Provigil for the treatment of her fatigue related to multiple sclerosis. Based on a review of the records, the diagnosis does not appear to be in dispute. The patient remains gainfully employed despite significant fatigue. The patient was provided with samples of Provigil in January 2006 and the medication was effective in the treatment of her fatigue. The patient has requested authorization for continued treatment with Provigil. The Health Plan denied her request based on a determination that the medication is not medically necessary for treatment of her MS-related fatigue.There is no dispute of the patient’s diagnosis, nor the condition necessitating the treatment, fatigue related to multiple sclerosis. The efficacy of the medication in the treatment of the patient’s symptoms has been established.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous hormone pellet therapy for treatment of the enrollee, who reported fatigue, memory disturbance and insomnia. Findings: All three physician reviewers found that the medical evidence does not support the services at issue in this clinical setting. Testosterone pellets are compounded products which are not produced by any pharmaceutical company and are not approved by the U.S. Food and Drug Administration (FDA). There are many FDA-approved treatments available for menopausal symptoms. However, this patient has not reached menopause. Her hormone testing was normal, with no evidence of perimenopause, and normal testosterone levels.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested food allergy testing (IgG food sensitivity test) for treatment of the enrollee’s fatigue. Findings: Three physician reviewers found that the testing at issue is not supported by the peer-reviewed literature. IgG testing for food allergies is not supported by national guidelines. Currently, elevated IgG levels for particular food allergens are thought to reflect prolonged exposure to components of that food, rather than a sensitivity to that food. While research in this area is ongoing, and may be found to be useful for some indications in future, at this time IgG testing has not been established as likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for fatigue was denied, the published record says the denial is worth fighting.