Can symptomatic management of Long COVID and related conditions be provided in-network?

Administrative Denial Response: Long COVID Symptomatic Management

The symptomatic management services requested for this patient's Long COVID can and should be provided within the GHC-SCW network, as these services do not require specialized expertise unique to Mayo Clinic. 1

Clinical Context

This patient presents with confirmed persistent long COVID (>12 weeks post-infection from 8/11/25) with classic symptomatology including fatigue, insomnia, polymyalgias, and brain fog. 1 The current treatment plan includes:

• Low-dose naltrexone 1.5mg nightly for fibromyalgia-like symptoms
• NSAIDs/acetaminophen for pain control
• Exercise recommendations (10-15 minutes daily)
• ADHD medication management

Why In-Network Care is Appropriate

Standard Assessment and Management Available In-Network

Long COVID is fundamentally a diagnosis of exclusion requiring standard primary care and specialty capabilities, not tertiary center expertise. 1 The ESCMID guidelines explicitly state that any patient with persisting symptoms >12 weeks after acute COVID-19 should be referred to medical care, but this refers to standard medical assessment, not specialized centers. 1

Required Diagnostic Workup (Available In-Network)

The recommended evaluation includes: 1

• Basic laboratory testing: CBC, CRP, kidney function, liver function tests
• Symptom-specific labs: Thyroid function (for fatigue), fasting glucose/HbA1c (metabolic screening)
• Cardiac evaluation if indicated: Troponin, CPK-MB, BNP for chest pain/palpitations
• Pulmonary function testing: For persistent dyspnea (though evidence is insufficient to recommend routine PFT for all patients) 1

None of these diagnostic procedures require Mayo Clinic-level expertise. 1

Evidence-Based Management Approach (Available In-Network)

Current long COVID management focuses on symptom-based supportive care with a multidisciplinary approach, which is deliverable in community settings: 2, 3, 4, 5

Step 1: Energy Conservation and PEM Prevention

• Pacing strategies to prevent post-exertional malaise (PEM), the cardinal feature of long COVID 2, 5
• Activity must be carefully titrated below the threshold that triggers symptom exacerbation 2, 5
• Critical caveat: The current recommendation for "at least 10-15 minutes daily exercise" may be inappropriate if it triggers PEM and should be reassessed 2

Step 2: Symptomatic Pharmacotherapy

• Pain management: NSAIDs, acetaminophen, potentially gabapentinoids or low-dose naltrexone (already prescribed) 4, 5
• Sleep disturbance: Sleep hygiene, melatonin, trazodone, or other sedating agents 4, 5
• Cognitive symptoms: Stimulant medications may help but risk worsening PEM 2, 5
• Dysautonomia: Beta-blockers, midodrine, fludrocortisone as indicated 2, 5

Step 3: Rehabilitation Services

• Physical therapy with careful attention to activity tolerance 2, 3, 4
• Occupational therapy for energy conservation techniques 2, 4
• Cognitive rehabilitation for brain fog 2, 4

Step 4: Comorbidity Management

• ADHD management (already being addressed with methylphenidate) 2
• Chronic fatigue syndrome overlap requires similar management strategies 2, 4

No Specialized Interventions Requiring Tertiary Center

There are currently no evidence-based, Long COVID-specific treatments that require Mayo Clinic expertise. 2, 3, 4, 5, 6 The 2025 multidisciplinary guidance statement explicitly notes that "to date, there are limited data to guide medication management specifically in the context of Long COVID" and that "medication use generally follows standard practice." 2

The only potentially specialized intervention mentioned in recent literature is stellate ganglion block (SGB) for dysautonomia, but this: 7

• Is based only on case reports and small studies, not established evidence 7
• Requires repeated procedures as effects wane 7
• Should be part of comprehensive treatment, not standalone 7
• Is not mentioned in the referral request

Clinical Recommendation

This patient should receive longitudinal, structured follow-up in primary care with access to in-network specialists (pulmonology, cardiology, neurology, psychiatry) and rehabilitation services as symptoms dictate. 2, 3, 4 The 2021 primary care guidelines specifically emphasize that "patients with long COVID-19 should be managed using structured primary care visits" with "holistic, longitudinal follow-up in primary care, multidisciplinary rehabilitation services." 4

Specific In-Network Services Needed

• Primary care visits every 4-8 weeks for symptom monitoring and medication adjustment 4, 5
• Physical medicine and rehabilitation consultation for comprehensive rehabilitation planning 2
• Cardiology if palpitations or chest pain warrant further evaluation 1
• Pulmonology if dyspnea persists or worsens 1
• Neurology for persistent cognitive symptoms or headaches 2, 4
• Pain management for refractory myalgias 4, 5

What Mayo Clinic Does NOT Offer That In-Network Cannot Provide

The Mayo website describes "self-management tools" and "activity rehabilitation programs" for post-COVID syndrome. 2, 3, 4 These are standard rehabilitation approaches available through in-network physical therapy, occupational therapy, and physiatry services. 2, 3, 4

Common Pitfalls to Avoid

• Do not recommend aggressive exercise programs without first establishing the patient's PEM threshold 2, 5
• Do not dismiss symptoms as psychological when they represent genuine post-viral pathophysiology 2, 4
• Do not pursue extensive testing for every symptom when basic workup is negative and symptoms are consistent with long COVID 1
• Do not prescribe stimulants for cognitive symptoms without considering their potential to worsen fatigue and PEM 2, 5