Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Procedure code 43644 (weight loss surgery). 

The insurer denied coverage for procedure code 43644 (weight loss surgery). 

The denial is overturned. 

As per the medical records, this patient had a past medical history of endometriosis, hyperlipidemia, hypothyroidism, obstructive sleep apnea (OSA), anxiety, and obesity. The doctor noted in a progress note that the patient was referred by her Primary Care Physician as an initial bariatric consult. He noted that the patient has had long standing obesity with multiple attempts at traditional, non-surgical, personal and supervised weight loss attempts. He noted the patient has a body mass index (BMI) of 36.9. He noted that he reviewed the steps necessary to go forward to have bariatric surgery. 

The patient was initially seen for nutritional assessment for bariatric surgery. Food and nutrition intake was reviewed as well as nutrition goals. 

The patient was seen again on for follow up on nutrition. The patient was advised to continue to follow preoperative bariatric nutrition guidelines. The patient was seen again by nutrition.  The patient was seen to complete her presurgical requirements. The provider noted that the patient has seen the nutritionist and is working on her diet, and she is exercising. He noted the BMI is 36.2. He also noted that she has sleep apnea. 

He noted that the patient has been seeing their dietician in order to obtain a presurgical weight loss goal of 5% (percent) weight loss from the initial visit. She currently weighs 217 pounds which is at her goal. She recently had laparoscopic hysterectomy with bilateral salpingo oophorectomy for endometriosis. He noted that they have talked about gastric bypass. 

The patient was seen for OSA evaluation. The patient underwent sleep study and the impression was mild OSA with mild significant oxygen desaturation during sleep with apnea hypopnea index (AHI) of 8.6 events/hour. 

The patient began treatment for psychotherapy and medication management, in order to better manage symptoms of depression and anxiety. She has remained treatment compliant and actively engaged in the therapeutic process. It was noted that the patient did not display any evidence of psychotic thinking and there appears to be no evidence that she experiences any personality traits that would interfere with her following the protocol. In summary she does not feel there is any psychological contraindication for surgery. 

The patient was seen for preoperative evaluation for gastric bypass. Her BMI was 36.64. The patient was cleared medically for surgery. 

Based upon the records provided and Milliman Care Guidelines (MCG) guidelines, the patient does meet the criteria and indications for bariatric surgery. The patient has a BMI greater than 35 with sleep apnea. She did have psychiatric clearance as well having tried weight loss in the past as well as has been followed by nutrition for multiple visits. She therefore 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 procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: Patient has BMI of 40 or greater, or adolescent patient (13 to 17 years of age) has BMI of 40 (or 140% of the 95th percentile in an age and sex matched growth chart) or greater, or Patient has BMI of 35 or greater and clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, nonalcoholic steatohepatitis... 

The insurer's denial of coverage for the procedure code 43644, weight loss surgery is reversed. Medical Necessity is substantiated.