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

The patient is a 20-year old woman who was initially evaluated by a rheumatologist in April 2002 and diagnosed with fibromyalgia and anxiety.  She was treated at that time with Paxil, Flexeril, and Vioxx and her provider reported a 90% improvement in her symptoms.  In November 2002, the record shows Paxil was discontinued and Lexapro was started due to weight gain and Flexeril was discontinued to improve athletic performance.  The providers notes from February 2003 again indicate fibromyalgia was under control and anxiety was the major issue.  In September 2003 there is no evidence of fibromyalgia while the patient was taking Lexapro, Flexeril, and Vioxx.  The record indicates the patient was participating in competitive swimming in April 2004 and an increase in tender points in her upper back was noted.  She was treated with trigger point injections in April and June of 2004.  The records from December 2004 indicate the patient was being treated with Flexeril, Mobic, and Prozac and she was noted to have diffuse fibromyalgia once again. Seroquel was started and she was referred for a trial of Therapeutic Electromagnetic Resonance (TMR) therapy.  At this point treatment with Lidoderm patches, ketoprofen gel with Flexeril, a TENS unit, and acupuncture had failed to relieve her symptoms.TMR therapy began in January 2005 and after the first treatment the patient reported a dramatic improvement in her symptoms and her subjective pain level decreased from 7 on a 0 to 10 scale to 0.25.  By the end of February 2005 the patient discontinued Prozac, Flexeril, and Mobic and her pain level increased to 2 on a 0 to 10 scale.  By March 2005 her provider states she is 90% better after TMR. She had continued treatment with Seroquel 25mg per day during this period of time. In total, the patient had 21 TMR treatments and over time her subjective pre-treatment pain level decreased.The Health Plan has denied coverage for the TMR therapy stating it is not a recognized treatment for fibromyalgia and therefore was not medically necessary.A thorough search of the medical literature yielded only one study dealing with TMR therapy for the treatment of fibromyalgia.  This study reported mixed results.  A second study dealing with static magnetic fields for the treatment of fibromyalgia failed to show any significant difference in symptoms after six months of treatment.  At this time, treatment of fibromyalgia with TMR is not the standard of care.It should also be noted that in April 2002 the patient demonstrated a 90% improvement in her symptoms with medical management of her fibromyalgia.  In March 2005, a 90% improvement was again noted after her TMR therapy and concurrent treatment with Seroquel. It is possible the patients improvement was due to the use of Seroquel rather than TMR therapy since medical management had been effective in the past.  Based upon the information provided, there is insufficient evidence demonstrating the need for TMR therapy in this case.For the reasons set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.