Appeal type: Medical necessity
Decision: Overturned

This is a patient who has medically complicated obesity. Her weight  was 207 pounds (lbs). She is 64.5 inches tall. This corresponds to a body mass index (BMI) of 35 kilograms per square meter (kg/m2). A bariatric preoperative note notes a BMI of 36.1. The records indicate that the patient has been significantly overweight for many years. She has attempted weight loss with conventional diet programs. The patient has comorbid health conditions of anxiety and depression for which she uses Lexapro and Wellbutrin. She is also reported to have sleep apnea. A polysomnogram (PSG) identified sleep apnea for which treatment options include positive airway pressure therapy, oral appliance and surgical intervention in addition to weight loss. The submitted records include progress notes which correspond to ongoing counseling for weight loss.
The patient sought bariatric surgical evaluation and was enrolled in a comprehensive, multidisciplinary, bariatric program with Dr. Ahmad. She has undergone nutritional counseling. She received nutritional counseling and education. A psychological evaluation was completed revealing no mental health contraindication for the proposed surgery.
Following this evaluation, the patient was considered to be a suitable candidate for laparoscopic sleeve gastrectomy. The health plan's determination is overturned.
The current standard of care for successful candidacy for bariatric surgery such as laparoscopic sleeve gastrectomy are: BMI of 40 kg/m2 or a BMI of 35 kg/m2 in association with weight related comorbid illnesses such as hypertension, diabetes, sleep apnea, osteoarthritis, etc. There must also be documentation of prior nonsurgical attempts at weight loss, nutritional counseling/education, mental health clearance for the proposed surgery, and commitment for long term follow up post bariatric surgery.
In this case the patient has a body mass index of greater than (>) 35 kg/m2 in conjunction with comorbid illness of obstructive sleep apnea confirmed by PSG. She has successfully completed a comprehensive multidisciplinary evaluation that includes surgical, psychological and nutritional components. She has followed with this program over a period of 8-months with refractory class II obesity. 
Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. 
This patient has significant weight related illness (obstructive sleep apnea) that will respond favorably to the weight loss anticipated with sleeve gastrectomy.
LSG (laparoscopic sleeve gastrectomy), is medically necessary for this patient based on the current standard of care and evidence-based literature for the following reasons:
(i) The patient meets the widely accepted National Institute of Health (NIH) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure (BMI of >35 kg/m2, comorbid conditions of sleep apnea, failed nonsurgical efforts to promote weight loss documented by progress notes and participation in a multidisciplinary preparatory program over an 8-month period.
(ii) The patient has been evaluated by a multidisciplinary bariatric program. The progress notes corresponding to the supervised preparatory program document behavioral modification, consultation with a dietician, monthly progress notes, and counseling regarding a reduced calorie diet program. She has also completed a mental health evaluation.
(iii) The LSG procedure has garnered the support of ASMBS guidelines and has proven efficacy and 5-year weight loss comparable to other bariatric procedures.