Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity 
Treatment: Weight loss surgery 
 
The insurer denied the weight loss surgery. The denial was upheld. 

This is a female patient with a history of prediabetes, high triglycerides, obesity and gastrointestinal reflux. The patient began gaining weight after rupturing L4-L5 which was fused once and failed. A second fusion surgery was done a few months later. She was house bound for a year and only able to use a walker to move from bed to bath. Her highest weight was 203 and now it was 194. She has not tried weight loss medications. The patient consulted a nutritionist who reviewed with her a diet progression for endoscopic sleeve gastrectomy procedure. The patient underwent upper GI endoscopy and gastroplasty. The Apollo overstitch device and endoscopic sleeve gastroplasty with reduced stomach volume was performed successfully. 

According to MCG Health Inpatient and Surgical Care 24th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (ISC)  the procedure is indicated by all of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: Patient has BMI of 40 or greater or patient has BMI of 35 or greater and clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis) or adult patient has BMI of 30 or greater with type 2 diabetes mellitus with inadequately controlled hyperglycemia (e.g., hemoglobin A1c greater than 8% (64 mmol/mol) despite optimal medical treatment (e.g., oral medication, insulin); Patient is candidate for bariatric surgery as indicated by all of the following: Patient has demonstrated reliable participation in preoperative weight-loss program that is multidisciplinary (e.g., low-calorie diet, supervised exercise, behavior modification); Current substance abuse not identified; Expectation that patient will be able to adhere to postoperative care (e.g., judged to be committed and able to participate in postoperative requirements); Patient is receiving treatment in multidisciplinary program experienced in obesity surgery that can provide all of the following: Surgeons experienced with procedure, Preoperative medical consultation and approval, Preoperative psychiatric consultation and approval, Nutritional counseling, Exercise counseling, Psychological counseling, Support group meetings. This patient has a BMI of 31.21 and did not meet any of the parameters that are needed so that one should be approved for bariatric surgery. 

As per ASMBS Endorsed Procedures and FDA Approved Devices Published March 2019, endoscopic gastroplasty is not a procedure endorsed as an approved procedure for bariatric surgery and is considered as an investigational procedure. 

As per Dr. Lim in "Bariatric procedures for the management of severe obesity: Descriptions" in UpToDate with topic last updated Feb 03, 2020 endoscopic sleeve gastroplasty (ESG), also known as endoluminal vertical gastroplasty, is an endoscopic approach for suturing the stomach that offers the potential to perform gastric-restrictive procedures endoscopically. As noted, "The anterior and posterior walls of the stomach are suctioned together, and then held in place by either a stapler or T-fastener device to create a tube of stomach similar to the SG. Additional fasteners or staples can be applied until the desired lumen size is achieved. At one year, the expected excess weight loss ranges from 27 to 58 percent. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for weight loss surgery is not substantiated.  The insurer's denial is upheld.