Diagnosis: Crohn's disease
Treatment: Injection of Infliximab in a Hospital Setting
The insurer denied the injection of infliximab in a hospital setting.
The health plan's determination is upheld.

This patient is a female with a history of Crohn's disease. She is on treatment with infliximab infusions. Under review is the medical necessity infliximab infusions at the hospital-based outpatient infusion center.

The injection of infliximab in a hospital setting is not medically necessary for this patient.

Continuation of infliximab is appropriate. However, there is no medical necessity for the infusions to be at the hospital outpatient setting. The patient has no documented reactions to prior infusions of infliximab. There is no change of treatment or dose adjustment that might be associated with adverse events or intolerance. There is no evidence that the hospital infusion center is safer than an independent office-based infusion center. This patient can safely continue her treatment at an independent infusion center. Hospital based infusions are not proven to be safer or more effective.

It was noted in recent publications that home based infusions are associated with suboptimal outcomes in inflammatory bowel disease patients. However, these observations do not apply to independent infusion sites or office based office-based infusions.

Therefore, medical necessity for the hospital-based infusion cannot be established.