Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Refractory morbid obesity
Treatment: Revision of Prior Bariatric Surgery
The health plan denied Revision of Prior Bariatric Surgery. The denial is overturned.

The patient is an adult woman who underwent laparoscopic adjustable gastric banding in 2015. This was performed as treatment for morbid obesity. She was not successful with post-surgical weight loss. Currently, the patient is 62 inches tall and weighs 240 pounds. This corresponds to a body mass index of 42. Additionally, she has comorbid health conditions of hyperlipidemia, hypertension and asthma. The band was previously adjusted to provide restriction. The records do not state how much fluid is currently in the gastric band.

The patient has the support of her endocrinology physician for the proposed revisional bariatric operation. The letter provides medical clearance for bariatric surgery. TSH (thyroid stimulating hormone a few months ago was 2.26 (normal).

The patient sought evaluation for revisional bariatric surgery. Contrast UGI (upper gastrointestinal series) a few months ago showed anatomic changes of lap band surgery. EGD (esophagogastroduodenoscopy) showed a normal esophagus with evidence of a gastric band at the level of the cardia. The patient has consulted and followed with a registered dietician on a number of times and has received nutritional counseling and education. A mental health evaluation this year yielded a favorable recommendation for bariatric surgery. The patient's surgeon has proposed removal of the existing lap band with conversion to duodenal switch.

The health plan denial letter states that there is no technical failure or major complication. There is no uncontrolled reflux. There has been no attempt at manipulation or adjustment of the band. The denial is being appealed.

The requested removal of lap band with conversion to duodenal switch is a medically necessary health service for this patient with refractory morbid obesity. This treatment is also consistent with medical standards within the bariatric surgical community as a safe and effective therapy for a patient with refractory morbid obesity post lap band surgery. This therapy is provided for the purpose of treating the condition of morbid obesity, is an appropriate intervention considering the potential benefits and harm to the patient, is known to be effective in improving health outcomes, and is effective compared to alternative interventions, including no intervention.

Revision to duodenal switch will promote weight loss of more than 60% excess body weight. This degree of post-surgical weight loss compares favorably to the weight loss associated with gastric band. With this anticipated weight loss there will be improvement or resolution of comorbid health condition that include hyperlipidemia, hypertension.

This patient has an appropriately positioned and adjusted gastric band in place at the cardia of the stomach. However, this purely restrictive bariatric intervention has not yielded the weight loss that this patient requires. The proposed conversion to duodenal switch offers this patient both enteric restriction of sleeve gastrectomy and malabsorption of the duodenal switch procedure and is associated with weight loss of more than 60% of excess body weight [1, 2, 6, 7]. The patient has successfully completed a comprehensive pre-surgical program with nutritional, medical, surgical and mental health components. Based on the available material, this patient does satisfy criteria of medical necessity for revisional bariatric surgery at this time per guidelines and standards of care within the bariatric surgical community as established by The American Society for Metabolic and Bariatric Surgery.