Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity
Treatment: Surgical Services (All)
The health plan denied the requested surgical procedure.
The health plan's determination is overturned.

This patient is a woman under consideration for bariatric surgery. She was 64 inches tall and weighed 209.2 pounds (lbs). This corresponds to a body mass index (BMI) of 35.9 kilogram/meter (kg/m2). She has comorbid health conditions of sleep apnea for which continuous positive airway pressure (CPAP) has been prescribed, hyperlipidemia, and pre-diabetes. Polysomnography has confirmed the diagnosis of sleep apnea. The patient has attempted weight loss with conventional weight loss programs as detailed in the surgical assessment. Unfortunately, she has not been successful with significant sustained weight loss.
The patient sought evaluation for bariatric surgical consultation. The records indicate that she was entered into a multidisciplinary bariatric program. Psychological evaluation provided mental health clearance. The patient consulted with a registered dietician and received nutritional counseling and education. Cardiology clearance was granted. Her thyroid stimulating hormone (TSH) was normal. Following this evaluation and because of persistent medically complicated obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).
At issue is the medical necessity for the requested weight loss surgery.

The health plan's determination of medical necessity is overturned, in whole.

Yes. Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed sleeve gastrectomy procedure is medically necessary for this patient. She has a BMI in excess of 35 kg/m2 with weight related comorbid health conditions that include sleep apnea for which CPAP has been prescribed, hyperlipidemia, and pre-diabetes. Polysomnography has confirmed the diagnosis of sleep apnea. These are weight-related health conditions that will respond favorably to the sustained weight loss associated with sleeve gastrectomy. The patient has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has cardiology clearance and normal thyroid function.
Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 kg/m2 in association with weight related illness of sleep apnea for which CPAP has been prescribed, hyperlipidemia, and pre-diabetes. There is documentation of prior nonsurgical weight loss efforts. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical evaluation with lab data and is felt to be an acceptable candidate. Finally, the treatment plan includes pre and post op dietary/ nutritional counseling.
From the available data it can be expected that laparoscopic sleeve gastrectomy would be health beneficial for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed bariatric operation.
Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy as is stated in the health plan denial letter. This patient's condition warrants treatment as is proposed and this treatment would be expected to be health beneficial for her and is consistent with nationally accepted guidelines of care. The proposed laparoscopic sleeve gastrectomy is medically necessary in this case per accepted guidelines for the care of medically complicated obesity.