Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Biliopancreatic diversion with duodenal switch and inpatient admission

The insurer denied coverage for biliopancreatic diversion with duodenal switch and inpatient admission.

The denial is overturned.

As per the medical record note, this is a patient with a history of morbid obesity, hypertension (HTN), sleep apnea, probable fatty liver and insulin resistance who has been followed by their primary care and referred for multiple obesity related issues. The patient has a body mass index (BMI) of 47. The patient understands the need for lifetime vitamins and supplements, and compliance to healthy diet and avoiding alcohol.  The plan was to get sleep testing and get the patient on continuous positive airway pressure (CPAP) as well as to see a psychiatrist and dietician.

Labs included were a hemoglobin A1c (HbA1c) of 5.0, normal thyroid stimulating hormone (TSH) as well as lipid profile, Vitamin E, zinc, and complete blood count (CBC). Preoperative Chest X-Ray (CXR) was normal.

This patient has a BMI (body mass index) much greater than 40 with OSA (obstructive sleep apnea). The patient therefore clearly meets the criteria for bariatric surgery. This patient completed a multidisciplinary program and does meet the National Institute of Health (NIH) requirements for bariatric surgery. The fact that the insurer is denying the procedure because they state the outcomes of the procedure is uncertain and that it has not been proven that it improves health outcomes over usual standard procedures performed for weight loss is incorrect. This patient needs to lose weight and needs bariatric surgery so that he can improve his health. The provider feels given everything and his experience, that this procedure has the best chance of giving this patient a sustained and good outcome. It has been used and is a proven procedure with good outcome.

Biliopancreatic diversion is one of the procedures that is recommended for patients with severe morbid obesity such as this patient. It is as good as RY-GB (Roux-en-Y Gastric Bypass), and it combines both a stomach procedure as well as an intestinal procedure which can lead to better weight loss for these patients with severe morbid obesity.

To summarize, the denial is reversed, and coverage should be provided for biliopancreatic diversion with duodenal switch and inpatient admission as the procedure is likely to be as beneficial as any of the other standard bariatric procedures. In fact, there is greater likelihood that the patient will have a better result with better weight loss with this procedure with improved health outcomes. It has the support of the ASMBS (American Society for Metabolic and Bariatric Surgery) and is likely to be as beneficial as the standard treatment for bariatric surgery. 

In summary, the denial of biliopancreatic diversion with duodenal switch and inpatient admission and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.