Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Inpatient Surgery (43860 x 1, 43659 x 1); repeat bariatric surgery
The insurer denied coverage for inpatient surgery; repeat bariatric surgery.
The denial is overturned.

According to the documentation provided, this patient has a history of obstructive sleep apnea (OSA), hypertension (HTN), osteoarthritis of knee, elevated hemoglobin A1C (glycated hemoglobin test), morbid obesity, and prior lap band surgery with removal of band due to band malfunction. The patient's body mass index (BMI) is 51.  

The patient was seen by the physician, who noted that the patient has gradually regained weight and is higher than his preoperative (preop) weight. It was attributed to Coronavirus disease (COVID) as well as having his lap band loosened a year ago to resolve acid reflux and concentric pouch dilation on esophagram. The provider noted that he started the process of band removal and converting to a stapled procedure but due to COVID constraints had stopped the process.

Operative report for the lap band removal was included where it was noted that the preop diagnosis was malfunction of the device, weight loss failure and intolerance to fills.

Another provider indicated in a note that the patient has been under her care and notes the patient has suffered morbid obesity for many years and has tried multiple diets and exercises but has been unsuccessful. His current BMI was 51.4. She noted he would benefit from bariatric surgery and the patient was medically cleared to pursue surgery at this time.

The patient was seen by another provider for psychological (psych) clearance. She noted that the patient had lap band surgery over a decade prior and the band was removed due to issues with the band. She noted that the patient seemed informed, motivated, and knowledgeable about the procedure. At the time of the interview, the provider did not note any psychological contraindications to having surgery. The patient was psychologically cleared for bariatric surgery.

Cardiology cleared the patient. 

The scientific evidence in peer reviewed literature does support an improvement in health outcomes. 

The procedure is an approved procedure by regulatory bodies.

This patient is a good candidate for bariatric surgery and for revisional surgery in the form of a mini bypass. He has a BMI of 51 with comorbidities and clearly meets the National Institutes of Health (NIH) criteria for bariatric surgery. He was cleared by psych as well as medicine and cardiology. 

It is one of several options that are present for patients who failed a prior restrictive procedure. It has similar weight loss results to Roux-en-Y Gastric Bypass (RYGB).

The risks are not overtly increased over standard treatment services. Although UpToDate (2) does point out that one-anastomosis gastric bypass (OAGB) has a relatively short operative time, low complication rate, and excellent weight loss outcomes, there is a concern for the high rates of alkaline bile reflux. There does not appear to be an associated risk of malignant degeneration. If the bile reflux becomes severe enough, a conversion to an RYGB is used as a rescue procedure. 

The patient meets criteria according to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC). This patient has a BMI of 51 and does meet criteria for weight loss surgery. His prior lap band failed and therefore required being removed and he needs revisional surgery for him to be successful and to lose weight. He did not have a sleeve as the insurer maintains.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of inpatient surgery (43860 x 1, 43659 x 1); repeat bariatric surgery should be overturned.