Diagnosis: Ulcerative Colitis
Treatment is testing for serum antibodies to Remicade
The insurer denied coverage for the testing for serum antibodies to Remicade
The denial is overturned

The patient has ulcerative colitis. He was being treated with infliximab, methotrexate, and prednisone. He had an increase of diarrhea and cramping. The infliximab levels was 1.9. He did not have antibodies.

Clinical Gastroenterology and Hepatology article titled "Appropriate Therapeutic Drug Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease" concluded that there was a consensus achieved towards the utility of therapeutric drug monitoring, particularly for anti-TNF [Tumor Necrosis Factor] therapies.

Inflammatory Bowel Disease article titled "Proactive In Drug Monitoring is Superior to Conventional Management in Inflammatory Bowel Disease" concluded that proactive therapeutic drug monitoring has higher mucosal healing rates and is associated with fewer surgeries than conventional non-therapeutic drug monitoring management.

This patient has ulcerative colitis and therapeutic drug monitoring has been shown to improve health outcomes.

The healthcare plan did not act with sound medical judgement therapeutic drug levels including measurement of serum antibodies is medically necessary.

The insurer's denial of coverage for the testing for serum antibodies to Remicade is reversed. Medical necessity is substantiated.