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

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. The enrollee indicates while she does practice pacing/resting and she monitors her heart rate as part of managing her illness, these methods do not treat her disease processes. They are tools to help improve her quality of life. She indicates there have been no approved treatments for this illness since chronic fatigue syndrome was first recognized as a medical condition. She notes her physician is working to address the underlying cause and treat the disease. Chronic fatigue syndrome, also known as myalgic encephalomyelitis, is a complicated disease characterized by unexplained, persistent, and relapsing fatigue. Many therapies have been utilized to treat this syndrome, which generally involve a multi-disciplinary approach to address underlying comorbid conditions, including depression, anxiety, and sleep disorders. There are many controversies regarding the optimal management of chronic fatigue syndrome and the use of unproven interventions may be potentially dangerous and often unnecessary. A number of medication, dietary, and behavioral interventions have been evaluated for the treatment of chronic fatigue syndrome to assess potential benefit to enrollees. Some interventions have clearly been found to be of no benefit. Use of anti-virals or antimicrobials has not proven beneficial versus placebo. The use of Aripiprazole (Abilify), a drug to treat depression, is unsupported to specifically treat chronic fatigue syndrome. Although the treatment for chronic fatigue syndrome is symptomatic, the enrollee has none of the FDA approved indications for any of the requested medications. Treatment options for chronic fatigue syndrome are limited. Treatment is largely supportive and focused on individual symptoms. A review of drug therapies for chronic fatigue syndrome/myalgic encephalomyelitis, indicate no universal pharmaceutical treatment can be recommended. The unknown etiology of chronic fatigue syndrome/myalgic encephalitis, and complications arising from its heterogeneous nature, contributes to the lack of clear evidence for pharmaceutical interventions. Patients report using a large number and variety of medications, which highlights the need for trials with clearly defined chronic fatigue syndrome/myalgic encephalitis groups. Trials based on more specific criteria are recommended to identify specific subgroups of patients in whom treatments maybe beneficial.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and infectious diseases and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.