Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 51-year-old female weighing 335 pounds with a body mass index (BMI) of 61. She has a number of comorbid conditions including hypertension, obstructive sleep apnea, and degenerative joint disease. The patients provider has recommended laparoscopic vertical gastroplasty/gastrectomy. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is more than adequate data regarding the requested procedure. All the published data show a higher failure rate for the requested procedure (greater than 50%) over the life of the operation. In fact, vertical gastroplasty/gastrectomy has a high revision rate compared to other weight loss procedures. Furthermore, it has been shown that patients in the super morbid obese group experience better results with a hybrid operation such as a duodenal switch operation than with a restrictive operation such as the requested procedure. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 51-year-old woman has a body mass index (BMI) of 61. She has severe obesity related complications that will improve or be eliminated by bariatric surgery. The patients plastic surgeon is proposing a laparoscopic vertical gastroplasty/gastrectomy. The Health Plan has denied coverage for the requested procedure on basis it is considered experimental.There are three basic types of bariatric surgery: purely restrictive, mixed, and purely malabsorptive. The American Society for Bariatric Surgery recognizes the three types of surgery. The first type is the restrictive vertical banded gastroplasty or lap band. The second type is the mixed Roux-en-Y gastric bypass, which is more restrictive than malabsorptive, or the duodenal switch, which is more malabsorptive and less restrictive but also has greater morbidity. The vertical gastroplasty/gastrectomy is a safe restrictive procedure, alone or staged as part of a Roux-en-Y or duodenal switch procedure. It is likely to be more beneficial for treatment of this super-obese patient and therefore, should be approved. Accordingly, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: This patient is a 51-year-old female with a body mass index (BMI) of 61 and comorbid factors of hypertension, sleep apnea, and degenerative joint disease. She has failed conservative weight loss measures.  She is a candidate for bariatric surgery and wishes to undergo laparoscopic vertical gastroplasty/gastrectomy. The Health Plan indicates the requested procedure is experimental.Review of the relevant medical literature reveals there is insufficient evidence of the efficacy of vertical gastroplasty/gastrectomy. The existing studies involve small numbers of patients. Issues regarding the durability of the procedure have been raised. Further studies are needed before vertical gastroplasty/gastrectomy can be recommended for patients such as this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.