Diagnosis: Peptic Ulcer
Treatment: Carafate suspension
The insurer denied the Carafate suspension.
The determination is overturned.

The patient has a peptic ulcer. Per the physician attestation for external appeal, she has failed sucralfate tablets. Coverage is requested for sucralfate suspension for the treatment of peptic ulcer. At issue is whether the formulary drug sucralfate tablet will be or has been ineffective, would not be as effective as the non-formulary drug, sucralfate suspension or would have adverse effects.

The request for sucralfate suspension is supported. Sucralfate is effective for the treatment of peptic ulcer disease [1-4]. Sucralfate is available in tablet and liquid suspension forms. Sucralfate and Carafate tablets are associated with the same indications and adverse side effects, although the patient has reportedly failed the tablet form of sucralfate. Per the physician attestation for external appeal, she has failed sucralfate tablets. No other records were provided. Therefore, the request for sucralfate suspension is supported for the treatment of peptic ulcer in this case.