Diagnosis: Constipation.
Treatment: Pharmacy/Prescription Drugs - Motegrity 1 milligram (mg) daily.

The insurer denied Pharmacy/Prescription Drugs - Motegrity 1 milligram (mg) daily.
The determination is overturned.

The patient has chronic idiopathic constipation. They presented with constipation, gas, and bloating; they tried Dulcolax, senna, magnesium hydroxide, and magnesium oxide. An x-ray of the abdomen showed dilated mid-small bowel loops, moderate stool in the left and rectosigmoid colon without distention of the right colon, and possible partial or intermittent small bowel obstruction. They failed prescription Linzess and Amitiza samples. Coverage is requested for Motegrity 1 milligram (mg) daily for the treatment of chronic idiopathic constipation.

At issue is the non-formulary medication, Motegrity.

The formulary drugs in this case have been reported ineffective and would not be as effective as the non-formulary drug (Motegrity). The patient has already reportedly failed Linzess and Amitiza; the formulary alternative lactulose, an osmotic laxative, was not attempted due to lack of coverage. However, the patient has already attempted magnesium-based osmotic laxatives (as well as the stimulant laxatives Dulcolax and senna). The most recent American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) or Linzess should be used if non-pharmaceutical laxatives fail, which has been documented in this case [1]. Motegrity is an effective therapy for the treatment of constipation and has demonstrated efficacy in high-quality clinical trials [2-5]. As the patient has failed Amitiza, Linzess, and stimulant and osmotic laxatives, the request for Motegrity is supported.