Diagnosis: Crohn's ileocolitis
Treatment: Formulary Exception for Uceris foam (budesonide)
The insurer denied coverage for Formulary Exception for Uceris foam (budesonide)
The denial is upheld

The patient has Crohn's ileocolitis and failed to respond to mesalamine. A colonoscopy last year showed active disease in the ileum and colon. The biopsy of the terminal ileum was read as active chronic ileitis. The rectal biopsy showed moderately active chronic proctitis. Her physician writes that she has tried Cortifoam but did not have improvement in her symptoms. She previously had a good response to Uceris.

The American Journal of Gastroenterology April 2018 Volume 113 has published an article titled "American College of Gastroenterology (ACG) Clinical Guideline: Management of Crohn's Disease in Adults." The article discusses medical management of mild to moderately severe disease. The article states that 5-aminosalicylic acid (5-ASA) suppository and enema preparations are effective for ulcerative colitis but the role of topical mesalamine in Crohn's disease is of limited benefit. Corticosteroids are often used as a bridge to permit symptom control. Controlled ileal release budesonide may be effective for short term relief of symptoms for patients with disease in the ileum and right colon. The recommended treatments for mild to moderately severe Crohn's disease include both Sulfasalazine and controlled ileal release budesonide. There is no recommendation to give steroid foams via the rectum.

Gastroenterology and Hepatology January 2020 Volume 16 Issue 1 has an article titled "A Comprehensive Review of Topical Therapies for Distal Ulcerative Colitis." The article discusses steroid foams. It states that a comparison of budesonide foam with classic corticosteroid rectal foam therapies demonstrated similar efficacies.

This patient has a diagnosis of Crohn's disease. The use of steroid rectal foams for Crohn's disease is not well established which is different from the treatment of ulcerative colitis. The physician in this case wants to give topical therapy for the rectal disease. However, the medical literature does not support that Uceris foam gives superior results as compared to Cortifoam. The formulary alternatives are not likely to cause the patient to have an adverse reaction. The Cortifoam has been reported to be ineffective. However, rectal foams are generally not effective for Crohn's disease. The ACG guideline advises controlled ileal release budesonide for patients with active ileitis.

It has not been shown that Uceris foam is superior to Cortifoam for Crohn's disease.

The carrier's denial of Request for Formulary Exception for Uceris foam (budesonide) to treat Crohn's is upheld.