Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for rheumatology follow-up visit at a tertiary care center.Fibromyalgia can be diagnosed and treated in the primary care setting. Referral to specialists is typically necessary only for patients in whom the diagnosis is uncertain or for patients who are refractory to therapy or with significant comorbid psychiatric issues. The routine treatment of fibromyalgia with pharmacologic therapy, such as Lyrica, and nonpharmacologic therapy, such and physical therapy, can be conducted by a primary care provider or a community based rheumatologist. Tertiary care center referral for rheumatology is not required for routine fibromyalgia management. In this case, referral to a specialized tertiary care center to see a rheumatologist for fibromyalgia is not indicated because this can be cared for by a community rheumatologist. The medical record indicates the patients current rheumatologist offered to increase Lyrica therapy to optimize control of fibromyalgia. This is not refractory fibromyalgia because the patient has declined increasing appropriate treatment; therefore, the disease remains uncontrolled. Thus, the requested rheumatology follow-up visit at a tertiary care center is not medically necessary for treatment of the patients fibromyalgia.Most patients with stable undifferentiated connective tissue disease generally have mild clinical manifestations typically demonstrating nonerosive inflammatory arthritis, mild Raynaud's phenomenon, and hematological abnormalities such as mild leukopenia or thrombocytopenia. These patients do not develop erosive or deforming arthritis, severe cutaneous manifestations, severe Raynaud's phenomenon or capillaroscopic changes consistent with systemic sclerosis, and do not have renal or neurological involvement. According to Mosca and colleagues, since patients with stable undifferentiated connective tissue disease have mild clinical manifestations, these patients are usually treated with short courses of low dose corticosteroids and antimalarial drugs. In these cases, undifferentiated connective tissue disease is typically stable over time and usually may require only mild therapeutic intervention or may not be treated at all. In this case, the patients condition is stable on Imuran and Plaquenil while prednisone was tapered off. The medical record does not report evidence of interstitial lung disease related to undifferentiated connective tissue disease with a normal CT of the chest in April 2021. The rheumatology record does not indicate symmetrical weakness suggestive of inflammatory myositis in the setting of an undifferentiated connective tissue disease. There was no report of skin thickening, sclerodactyly, skin ulceration or Raynauds syndrome to suggest systemic sclerosis features in the setting of an undifferentiated connective tissue disease. Given the undifferentiated connective tissue disease is stable, this can be monitored in the community setting and does not require tertiary care center referral. Therefore, the requested rheumatology follow-up visit at a tertiary care center is not medically necessary for treatment of the patients undifferentiated connective tissue disease.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.