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202210-154868

2022

Healthfirst Inc.

Medicaid

Digestive System/ Gastrointestinal

Pharmacy/ Prescription Drugs

Medical necessity

Upheld

Case Summary

Diagnosis: Crohn's Disease.
Treatment: Budesonide ER (extended release) 9mg (milligrams).

The insurer denied: Budesonide ER 9mg. The denial is upheld.

The patient is an adolescent female with weight loss, diarrhea, abdominal pain, and fatigue. She has terminal ileitis secondary to Crohn's disease. The request is for Budesonide.

The health plan denied coverage of the request, noting "State law requires us to approve Budesonide ER 9mg when the clinical information received is consistent with the approved U.S. Food and Drug Administration (FDA) or supported in at least one of the official compendia. We have communicated with your provider. At this time, the information that we have received from your provider does not show that the drug is supported as medically necessary to treat your specific health condition, and so we are unable to approve your request." The denial is being appealed.

The requested Budesonide is not medically necessary.

The request is for Budesonide ER (extended release) 9 mg (milligrams), which is more appropriate for use in ulcerative colitis or Crohn's colitis. This patient has terminal ileitis secondary to Crohn's disease. A more appropriate medication would be Budesonide EC (enteric coated) (or brand Entocort EC [enteric coated]), which is FDA (United States Food and Drug Administration) approved for Crohn's disease and is released in the terminal ileum.

Therefore, given the above, the requested Budesonide is not medically necessary.

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