Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Patient is a 38-year-old female diagnosed with morbid obesity.Findings:  The physician reviewer found that it was noted the patient has a history of two previous weight loss surgeries., most recently, a laparoscopic roux-en-y gastric bypass surgery in 2016. Since that time, the patient was noted to have been compliant with a diet and weight loss program.  Despite this, she was noted to have a weight gain of 5.3 pounds.  The patient has no other co-morbid conditions. On 4/15/22, the patients body mass index (BMI) was noted to be 35.9.  The provider is requesting authorization for a laparoscopic duodenal switch procedure for weight loss. The Health Plan indicates that the requested service is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plan has denied coverage for the requested service. At issue is whether Laparoscopic Duodenal Switch (CPT 43845) is medically necessary for the treatment of this patient. Mechanick and colleagues noted, obesity has been shown to significantly increase morbidity and mortality in patients, including increased risk of type 2 diabetes, osteoarthritis (OA), hypertension, and other cardiovascular diseases. It has been well-established that weight loss decreases morbidity and mortality and prolongs life.  Weight loss surgery has been shown to be safe and effective for weight loss, especially in individuals who have failed to lose weight with conventional weight loss strategies like diet and exercise.  Established guidelines have recommended weight loss surgery for patients with a BMI greater than or equal to 40 with no associated obesity co-morbidities or patients with BMI greater than or equal to 35 with associated comorbidities: these co-morbidities include, but are not limited to, hypertension, diabetes mellitis, sleep apnea, gastroesophageal reflux disease (GERD) and others. Elshaer and colleagues noted, weight gain after surgery or recidivism is a known risk of all weight loss surgeries.  Tran and colleagues stated, studies have shown benefit to revision surgery when patients fail to lose weight or regain weight previously lost.  Moon and colleagues noted Laparoscopic Duodenal Switch is a well-established option as a revision surgery for failed roux-en-y-gastric bypass (RYGB).  There are much smaller numbers of patients who report failure after RYGB converting to duodenal switch compared to failed sleeve gastrectomy and laparoscopic banding, although numerous case studies and reviews exist.  Duodenal switch has been shown to have higher risk of complications, however it is also highly effective for initial and long term weight-loss in select patients and experienced bariatric surgeons.  Patients being considered for revision weight loss surgery for weight re-gain must meet the same criteria as those considering initial weight-loss surgery: BMI greater than or equal to 40 without co-morbidities or greater than or equal to 35 with co-morbidities. In this case, the patient has had two previous weight loss surgeries (laparoscopic gastric banding and laparoscopic roux-en-y gastric bypass) and continues to be obese with a BMI of 35.9. Her current weight is 232.2 lbs which is 94.2 lbs (68%) over her ideal body weight of 138 lbs. There is no documentation of previous weight loss after RYGB. The patient does have a documented co-morbid condition of GERD; however, she seems to be well-controlled on a 20 mg daily dose of a proton pump inhibitor (PPI). A normal upper gastrointestinal study and normal esophagogastroduodenoscopy (EGD) without evidence of esophagitis was noted. In this case, there are no clearly defined obesity related co-morbidities. Therefore, Laparoscopic Duodenal Switch (CPT 43845) is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.