Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 48-year-old male with a BMI of 70.4. The patient has multiple comorbid conditions including hypertension, severe obstructive sleep apnea, and gastroesophageal reflux disease. He has failed conservative weight loss measures. The patient has requested authorization for vertical restrictive gastrectomy/gastroplasty. The Health Plan has denied the patients request indicating a vertical restrictive gastroplasty is considered investigational.Super morbidly obese patients are high operative risks. Therefore, a staged procedure is appropriate in this patient. Although there is support for the duodenal switch procedure in the super obese, which can be performed open as a single stage, this carries the risk of high morbidity. In addition, a purely laparoscopic duodenal switch is very difficult in the super obese. A vertical restrictive gastrectomy will lead to initial weight loss, which will then allow for a much less difficult duodenal switch procedure. Although two surgeries are necessitated, a staged procedure provides this patient with the most likely long-term benefit. As such, the requested procedure is an appropriate first step and is likely to be more beneficial for treatment of this high-risk patient.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 48-year-old male with a BMI of 70.4. The patient has failed past attempts at weight loss through diet and exercise. He has requested authorization for vertical restrictive gastrectomy/gastroplasty. The Health Plan has denied the patients request on the basis that the requested procedure is considered investigational.The data strongly supports the high failure rate of Roux-en-y gastric bypass in patients who are super morbidly obese. This patient will only benefit from an operation that combines the restrictive procedure with limitation of absorption. A gastrectomy will allow the patient to undergo a duodenal switch procedure at a later date and is likely to result in a better outcome than conventional gastric bypass surgery. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 48-year-old male with a body mass index of 70.4, placing him in the super morbidly obese category. As such, the patient is in the high-risk operative category. Given the patients weight and comorbid conditions, he qualifies for operative intervention. It has been recommended the patient undergo vertical restrictive gastrectomy/gastroplasty as a first intervention. The Health Plan has determined the requested procedure is considered investigational for treatment of the patients obesity.The patient is in the super morbidly obese category and carries a substantial increased risk of both morbidity and mortality with standard bariatric bypass surgery. Though the data is still limited, there is a clear indication that both morbidity and mortality can be reduced by staging the procedure using a gastric restrictive procedure to bring the patient down to a more appropriate weight prior to proceeding with a malabsorptive procedure. Based upon the provided data, there is sufficient clinical evidence to support the use of the requested procedure as a medically reasonable and appropriate first intervention. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.