Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old male with a working diagnosis of Familial Mediterranean Fever (FMF). His rheumatologist has understandably labeled this diagnosis as probable or presumptive at different times, though states that the diagnosis was confirmed under genetic screening. The physicians notes include reference to extensive evaluation involving at least twelve physicians in various specialties, though genetic screening actually revealed heterozygosity for FMF, making its significance for the diagnosis uncertain. The submitted records describe rather unexpected continuous and unrelenting pain rather than the more usual episodic pain associated with FMF. Thus, it appears the patient has experienced repeated and ongoing failure of pain management. The patient has been treated with a significant array of narcotics administered by mouth, by self-injection, by PICC line, and even attempted by pump infusion. After the patient failed or developed tolerance to all other pain-relieving agents, he was started on Actiq in what was intended to be a short-term intervention. As expected, Actiq produced initial pain benefit. A request has been made for continued use of Actiq. The Health Plan has denied the request on the basis the requested medication is not medically necessary for treatment of the patients medical condition. FMF is generally an episodic pain syndrome, the diagnosis of which is largely by exclusion. Though there is potential support of the diagnosis from genetic markers or tests such as metaraminol challenge, the role of these in this patients diagnosis is not stated. Colchicine, either orally or by intermittent intravenous, is generally the most effective agent for true FMF, though not all patients respond. The submitted records do not include a description of trials of colchicine. If colchicine was tried and failed, one further feature of typical FMF is missing in this case. In summary, there is evidence speaking against the diagnosis of FMF in this patient.The patients history is one of continuous pain requiring continuous and escalating narcotics with temporary benefit before needing to move to more potent agents. The tenor of this case history raises the possibility of other causes of pain or other issues leading to pain medication-seeking behavior. This patient is likely highly opiate dependent at present, and has probably become tolerant to all the usual agents. His physician initially suggested a short-term trial of Actiq to bridge a transition to longer-acting narcotics, which would be more appropriate for prolonged use. The prospect for success with Actiq is poor, as this short-acting, high-potency narcotic (approved only for very limited cancer-related treatment) will almost certainly lead to the same tolerance and loss of benefit noted with the patients previous medications. The Health Plans recommendation that the patient receive a second opinion to fully re-evaluate his condition is medically reasonable and appropriate.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.