Diagnosis: Chronic idiopathic constipation.

Treatment: Motegrity.

The insurer denied coverage for Motegrity.

The denial is overturned.

This is a female patient whose past medical history includes severe malnutrition, gastroparesis, mast cell activation syndrome (MCAS), and chronic idiopathic constipation. Her constipation did not respond to Reglan, fiber, Linzess, or Amitiza. It is also reported that she had failed numerous over-the-counter medications.

UpToDate has an article titled "Management of chronic constipation in adults." Prucalopride is listed as a treatment for severe constipation. Multiple trials were analyzed and showed an improvement in quality of life scores. This improvement was maintained up to 18 months.

This patient has severe constipation and has failed multiple other regimens including Linzess and Amitiza. It is also reported that she failed the over-the-counter medications. Prucalopride is appropriate for patients who have chronic idiopathic constipation and have failed other treatments.

The healthcare plan did not act in the best interest of the patient or with sound medical judgment. Motegrity (prucalopride) is a medically necessary treatment.

The insurer's denial of coverage for Motegrity is overturned. Medical necessity is substantiated.