Diagnosis: Diarrhea
Treatment: Octreotide Acetate
The insurer denied the Octreotide Acetate
The denial is upheld

The patient is a female with Crohn's disease and refractory entero-cutaneous fistula, with diarrhea. She has failed biologics, and is TPN (Total Parenteral Nutrition)-dependent. The provider is requesting treatment with Octreotide.

No, the Octreotide Acetate is not medically necessary.
While some studies suggest a possible benefit of the use of Octreotide in the management of enterocutaneous fistulas, literature continues to be inconclusive. Therefore, the requested Octreotide is not clinically appropriate, accepted standard of care or medically necessary in this patient.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As it is not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying