Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Weight loss surgery, procedure code 43848

The insurer denied coverage for weight loss surgery, procedure code 43848

The denial is overturned

As per the medical records, this patient a past medical history of morbid obesity, diabetes, hypertension and hyperlipidemia. He had a bariatric surgery evaluation. The BMI (body mass index) was 47.7 and the treating practitioner noted that the patient qualified for surgery by National Institute of Health (NIH) criteria. 

The patient was seen by physician for pulmonary preoperative assessment for bariatric surgery where it was noted that his respiratory status is excellent and suitable for operative intervention. Sleep study performed indicated mild sleep disorder breathing.

The patient underwent an esophagogastroduodenoscopy (EGD) where no significant erosive changes or hiatal hernia was noted. The proximal portion of the stomach that was previously fashioned into a sleeve did appear to be somewhat distended compared to typical. There were no significant contraindications to proceeding with planned revision of gastric sleeve to bypass. Pathology of the biopsy was only significant for chronic gastritis. Labs were included for review.

The doctor noted in a letter that the patient was seen a nutrition consultation in preparation for bariatric surgery. She noted the body mass index (BMI) of 46.3 and his morbid obesity history and attempts at weight loss. She noted the patient has tried gastric sleeve, low carbohydrate without lasting success. Dietary instruction regarding diet pre and post was given, and she recommended that the patient attend support groups and educational workshops.

Psychologist noted in a letter that the patient was seen for psychiatric evaluation. He noted the patient to be well motivated and that there was no obvious psychopathology or cognitive defects noted. He appeared well able to grant informed consent and well able to follow post-surgery directives.

The patient was seen for bariatric surgery follow up for monthly supervised dieting prior to bariatric surgery. Report of limited upper gastro intestinal series (UGI) was documented where it was noted that there was no hiatal hernia; no extravasation of contrast, no reflux noted, and the gastric sleeve was not dilated.

The patient was seen by registered dietitians for monthly dieting and nutritional visits.

The patient cardiology clearance and was found to be acceptable cardiovascular risk for surgery.

Based upon the records provided and the Milliman Care Guidelines (MCG) guidelines, the patient does meet the criteria and indications for bariatric surgery. The patient has a BMI greater than 40. He did have psych clearance as well having tried weight loss in the pass as well as has been followed by nutrition for multiple visits. Therefore, the patient does meet the criteria set forth by MCG guidelines.

According  to MCG Health Inpatient and Surgical Care 25th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy the patient does meet guidelines to warrant a bariatric procedure as he does have a BMI greater than 40.  

He has been cleared by psych and has undergone nutrition consultation. He has been cleared by his medical provider for surgery as well. In addition, the operative criterion for this surgery is inpatient stay as well.

The health care plan did not act reasonably and with sound medical judgment in the patient's best interest.

The insurer's denial of coverage for weight loss surgery, procedure code 43848, and inpatient stay is overturned. Medical Necessity is substantiated.