Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Revision of Gastric Bypass (weight loss surgery code 43860 and 43845) and Inpatient Hospital Admission
The insurer denied: Revision of Gastric Bypass (weight loss surgery code 43860 and 43845) and Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass) 15 years ago. This was performed as treatment for morbid obesity. Then 2 years ago she underwent gastric banding for the condition of weight gain. A mental health assessment 3 months ago states that she has experienced complications and no significant weight loss subsequent to the lap band surgery. This evaluation states that the patient is seeking revisional bariatric surgery to address health complications related to obesity and to improve her functioning. An upper endoscopy from last year describes Grade A esophagitis and gastric bypass anatomy. This report states that 'the examined duodenum was normal but does not describe the estimated size of the gastric pouch or the specific appearance of the gastrojejunal anastomosis.  Three months ago, the patient was 67 inches tall and weighed 245lbs (pounds) (BMI (body mass index) of 38.4 kg/m2 (kilograms per meter squared). The medical evaluation lists abdominal pain, intermittent dysphagia, fatty liver, GERD (gastroesophageal reflux disease), hyperlipidemia, hypertension, peripheral vascular disease, sleep apnea, and shortness of breath among her comorbid health conditions. Nutritional notes dated 4 months ago states that her pre-gastric bypass weight was 277 lbs (pounds) and her post-surgical nadir was 150 lbs (pounds). A surgical progress note dated last month from the patient's provider states that the patient was status post robotic lap band removal and was doing well and tolerating a diet. A letter from the patient's provider states that the proposed surgery is a bypass revision with gastrojejunostomy (Resection/Resize of gastric pouch), CPT (Current Procedural Terminology) code 43860/43845 for morbid obesity, hypertension. 

The proposed treatment of Revision of Gastric Bypass (weight loss surgery- code 43860 and 43845) and Inpatient Hospital Admission is not considered medically necessary. 

The submitted records do not support that the requested procedures are medically necessary for this patient [Bypass revision with gastrojejunostomy (Resection/Resize of gastric pouch), CPT code 43860/43845 for morbid obesity, hypertension.] 

The submitted records do not establish that this patient specific complications complicating the roux en Y gastric bypass procedure that require revision of the gastric pouch or gastrojejunal anastomosis. While she did undergo a gastric banding procedure 2 years ago and did experience some dysphagia subsequent to the banding procedure, the records indicate that the lap band was removed recently. 
The available documentation does not support that revisional bariatric surgery is medically necessary per the health plan guidelines or generally accepted medical standards. The patient has been evaluated with upper endoscopy performed last year (prior to the removal of the lap band) that does not describe any specific pathology of the gastric bypass anatomy that would support the medical necessity of the proposed revisional operation to promote weight loss. The proposed revisional surgery to reduce the size of the gastric pouch or to further restrict the gastrojejunal anastomosis are not clinically appropriate for the diagnosis or treatment of the patient's condition (BMI (body mass index) 38 kg/m2 and associated weight related illness) and are not known to be effective for the patient's condition. There is no published clinical data to support the medical necessity of the proposed revisional operation for this patient's documented condition post roux en Y gastric bypass.