Issued and entered April 6, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On February 27, 2003, XXXXXXXXXXX, (Petitioner) filed a request for an external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. The Commissioner’s staff assessed the material submitted by the Petitioner and accepted the request.

A determination on medical issues was required. The Commissioner assigned the case to an independent review organization (IRO), as provided in MCL 550.1911(6). The IRO submitted its external medical review on March 20, 2003.

II
FACTUAL BACKGROUND

On XXXXXXXXXXXX, the Petitioner complained of chronic muscle pain, chronic fatigue and insomnia. Her medical history includes thyroid hormone supplementation for autoimmune thyroiditis. Petitioner’s physician ordered extensive laboratory testing for the evaluation of chronic fatigue syndrome, fibromyalgia syndrome (CFIDS).

American Community Mutual Insurance Company (American Community) covered the office visit and baseline studies for EBV, CVC, basic chemistries and thyroid hormone status. The additional laboratory tests, which included analysis for vitamins, heavy metal, organic levels, spirometry, ECG, ova and parasites were denied as not medically necessary for the diagnosis and treatment of Petitioner’s condition.

III
ISSUE

Did American Community comply with the terms of its Certificate of Insurance when it denied payment for laboratory tests performed on XXXXXXXXXXX?

IV
ANALYSIS

Petitioner’s Argument

The Petitioner has an extensive history of complaints of chronic muscle pain, chronic fatigue and insomnia. Her medical history includes unsuccessful thyroid hormone supplementation for autoimmune thyroiditis. Petitioner has seen multiple physicians and tried multiple treatment plans with no relief. Since Petitioner had a history of unsuccessful treatment, her physician believed it was imperative to evaluate the Petitioner for chronic fatigue syndrome, fibromyalgia syndrome versus other disease processes that may mimic these diagnoses. Dr. XXXXXX ordered extensive laboratory tests.

On XXXXXXXXXXX, her doctor wrote a letter to American Community noting the tests were medically necessary. He stated that without this significant work-up, Petitioner would have bounced around the medical system for years before a proper treatment plan would have been prescribed. Based on the laboratory data, chronic fatigue syndrome was diagnosed. A treatment plan was designed to improve the petitioner’s functional mitochondria myopathy, immune status, keep chronic viral infections under control and overall improve her functional ability.

American Community Mutual Insurance Company’s Argument

American Community issued its final adverse determination on December 10, 2002. American Community denied coverage for the lab charges claiming they were not medically necessary. American Community states:

Medically Necessary procedures are medical, surgical, psychiatric, substance abuse or other health care services, supplies, treatments, procedures, drug therapies, or devices, which are determined by us to be necessary to treat the Family Member’s condition. Determination of medical necessity is done on a case-by-case basis and considers several factors including, but not limited to, the standards of the medical community. The fact that a physician has performed or prescribed a procedure or treatment or the fact that is may be the only available treatment for a particular injury or sickness does not, alone, mean that it is Medically Necessary. In addition, the service must, in our judgment, be:

1. Consistent with the diagnosis or and prescribed course of treatment for the Family Member’s condition;
2. Required for reasons other than the convenience of the Family Member or his/her physician, and not required solely for custodial, comfort, or maintenance reasons;
3. Performed in the most cost-effective type of setting appropriate for the condition;
4. Rendered at the frequency which is accepted by the medical community;
5. Likely to be effective in treating the Family Member’s condition; and
6. Not experimental, investigational or Unproven Procedure.

They further stated:

There is no data submitted to support the validity or value in the assessment and treatment of this disorder. It has been determined that the claims for the lab charges in question are excessive and without any evidence-based medicine behind them, making them not medically necessary.

Independent Review Organization (IRO) Recommendation

The IRO physician who reviewed this case is a practicing physician, board certified in anatomic and clinical pathology with special qualifications in cytopathology. The IRO physician reviewed all the documentation presented in this case and concluded the laboratory tests performed on XXXXXXXXXX, were not medically necessary for the diagnosis and treatment of Petitioner’s condition.

The IRO physician noted that the requested testing, including analysis of vitamin, heavy metal, organic levels, spirometry, ECG, ova and parasites had not been adequately justified. No evidence-based science substantiates this testing was necessary to obtain a diagnosis of chronic fatigue syndrome. Further, evidence-based science that details a therapeutic course for this disease was also absent.

Based on the documentation presented, the IRO concluded that the laboratory testing performed on XXXXXXXXXXXXX, was not medically necessary for the diagnosis and treatment of Petitioner’s condition.

Commissioner’s Review

The Commissioner carefully reviewed the documents submitted, the positions of the parties, as well as the recommendation of the IRO. After making this review, the Commissioner agrees with the IRO’s assessment of this case and finds that American Community properly denied payment for the laboratory tests performed on XXXXXXXXXXXX, as not medically necessary.

V
ORDER

The Commissioner upholds the American Community final adverse determination in this matter. This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.