Diagnosis: Crohn's Disease of the small intestine.
Treatment: Formulary Exception for Ortikos to treat Crohn's Disease.

The insurer denied coverage for a Formulary Exception for Ortikos to treat Crohn's Disease.

The denial is overturned.

This is a female patient who has Crohn's Disease of the small intestine. A video capsule test was done and a stricture in the terminal ileum was found. Treatment with Budesonide was advised.

The American College of Gastroenterology has published a clinical guideline: Management of Crohn's Disease in Adults. For mild to moderately severe disease recommendations for medical therapy are given. The guideline states that controlled ileal release budesonide at a dose of 9 milligrams (mg) once daily is effective and should be used for induction of symptomatic remission for patients with mild to moderate ileocecal Crohn's disease. The guideline also states that oral mesalamine has not consistently been demonstrated to be effective compared to placebo for induction of remission and achieving mucosal healing in patients with active Crohn's disease and should not be used to treat patients with Crohn's disease.

This patient has Crohn's disease with an ileal stricture. Controlled release Budesonide is a recommended treatment of the American College of Gastroenterology. The formulary drugs have been shown to not be as effective as the controlled release Budesonide. Based on the recommendations of the American College of Gastroenterology clinical guideline for the management of Crohn's disease in adults, the requested drug is likely to be more effective. The denial is overturned.

The insurer's denial of coverage for a Formulary Exception for Ortikos to treat Crohn's Disease is overturned.