Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid obesity

Treatment: Procedural code 43845 duodenal switch

The insurer denied coverage for procedural code 43845 duodenal switch.

The denial is upheld.

According to the documentation submitted, this patient has the medical diagnoses of morbidly obese and gastroesophageal reflux disease (GERD). This patient has a previous laparoscopic (lap) band gastric surgery, which is now reportedly complicated with severe GERD. This patient had gained all her weight back. This patient's provider has proposed a removal of the LAP (laparoscopic) Band, CPT (current procedural terminology) 43774: laparoscopic band removal and CPT 43845 duodenal switch. This is a review of this treatment plan. An upper gastrointestinal (GI) endoscopy showed normal esophagus and duodenum, erythematous mucosa in the antrum and normal band. Her doctor is requesting authorization for procedure codes 43774 laparoscopic band removal and 43845 duodenal switch; code 43845 was denied as experimental/investigational. The treating provider is requesting plan approval for treatment with surgical procedure on the stomach, procedure code 43845.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome for the requested.

As with this patient, with significant GERD, a duodenal switch surgery is to be avoided.      

Surgical procedure on the stomach, procedure code 43845 does need to have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for surgical procedure on the stomach, procedure code 43845.

Surgical procedure on the stomach, procedure code 43845 is not the best available treatment for this patient at this time.

The Roux-en-Y gastric bypass is the procedure of choice for patients presenting for bariatric surgery in the presence of GERD.     

The adverse risks are increased over standard treatment and/or services. The requested service is not likely to be more beneficial than any of the standard treatments and/or procedures for this patient.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome for the requested. The surgical procedure on the stomach, procedure code 43845 does need to have final approval from the appropriate regulatory bodies for this diagnosis. Most surgical procedures not requiring an associated device are not FDA (Food and Drug Administration) regulated. As with this patient, with significant GERD, a duodenal switch surgery is to be avoided. The Roux-en-Y gastric bypass is the procedure of choice for patients presenting for bariatric surgery in the presence of GERD. Therefore, the request is denied and not medically necessary for this patient.

Per Hanson, et al (2022), "Duodenal switch and single-anastomosis derivatives is documented as an esophageal prone reflux procedure and should be considered as avoided."

"Weight loss surgery is an efficacious treatment for patients with obesity; however, patients undergoing these procedures should have a thorough preoperative evaluation to ensure the best outcomes via proper patient selection. This activity reviews the pre-operative assessment and preparation for bariatric surgery and highlights the role of the interprofessional team in improving care for patients who undergo obesity surgery. Bariatric surgery is a highly effective treatment for obesity that has shown not only to assist with weight loss but to improve metabolic comorbidities in this patient population." (Benalcazar, et al [2022]).

"Conclusion: More studies are needed to compare surgical and endoscopic solutions. The choice of treatment depends on local resources and skills, and if necessary, refer the patient to a specialist center." (Butti, et al [2020]).

The carrier's denial of a surgical procedure on the stomach; procedure code 43845 should be upheld.