Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic inflammatory response syndrome
Treatment: human leukocyte antigen (HLA typing) laboratory testing
The insurer denied human leukocyte antigen (HLA typing) laboratory testing.
The determination is upheld.


This is a female patient who was seen for follow-up of chronic inflammatory response syndrome. The documentation indicates the patient is "...Due for more Omega's and spore biotics." There is also a plan to treat the patient with WelChol.
Laboratory results are provided from specimens collected. It indicates a large amount of left low coccus along with the sensitivity report.
She had been previously seen and was noted to have passed a visual contrast sensitivity test (VCS) test without further delineation of what this means. It notes the patient to have been taking "Omega's" as well as probiotics and black cumin. The patient is noted to have not started Prevalite (cholestyramine). The patient was diagnosed with suspected exposure to toxic mold.
The patient had been previously seen and was noted to have had a hard time losing weight. It was noted that she had failed a chronic inflammatory response (CIRS) screening.
A requisition form indicates the patient was ordered to undergo a number of testing codes, including celiac disease human leukocyte antigen (HLA) DQ [cell surface receptor protein found on antigen presenting cells] testing and celiac antibodies. Additionally, human leukocyte antigen (HLA)-DR B1 testing was ordered. Results of the HLA typing are reported and are available for review.
The contractor which performed the testing and question submitted correspondence stating that the testing performed is considered necessary purely by receipt of a requisition form. Prior to that, the patient was seen in the office as a new patient. She noted being very stressed at work and very emotional. She noted multiple familial stressors and poor sleep. It was noted that the patient has had coronavirus (COVID) with no history of vaccination. She also noted water damage to the house, failure of melatonin to address sleep and having had a hard time losing weight. A plan is noted for chronic inflammatory response syndrome screening and to restart probiotics.
A request for appeal was submitted on behalf of the patient. There is accompanying correspondence from the patient's physician stating that the patient has been exposed to water damaged buildings and mold and has been exhibiting signs and symptoms of chronic inflammatory response syndrome. It states that the requested testing is the only way to verify if the patient has the condition. At issue is the medical necessity of human leukocyte antigen (HLA typing) laboratory testing.

The HLA typing is not demonstrated to be medically necessary for this patient. It appears that the HLA typing was ordered as an evaluation for "Chronic Inflammatory Response Syndrome." This is not a recognized disease entity in the United States. There certainly are rare diseases associated with fatigue that have patients with certain HLA types, however there is no recommendation from any standard of care organization to check HLA typing for evaluation of fatigue. It appears that the patient was possibly suspected of having some variant of chronic fatigue syndrome, which once again has no HLA serology required. Additionally, it appears that celiac disease was considered, though the patient has no gastrointestinal complaints. Standard of care guidelines regarding celiac disease do not recommend HLA typing. Additionally, current expert opinion in the assessment of fatigue and adults does not recommend HLA typing as an assessment for fatigue. In this case, it does not appear that HLA typing has been recognized as a legitimate assessment simply due to fatigue and it is unclear why it was pursued in this case as there is no explanation in the clinician's notes. HLA typing in this case does not appear consistent with the standards of medical practice and therefore is not demonstrated to be medically necessary.