Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysphagia, regurgitation, and GERD
Treatment: Surgery To Remove Lap Band (procedure code 43774)
The insurer denied the Surgery To Remove Lap Band (procedure code 43774)
The denial is overturned. 

The patient is a male with a history of having undergone lap band surgery several years ago.  He presented multiple times with symptoms of dysphagia, regurgitation, and GERD (gastroesophageal reflux disease).  The band was decompressed of all fluid.  The patient reports vomiting with solid food meals for the past several months.  Upper endoscopy showed a dilated esophagus and esophageal dysmotility.  

The patient's provider has offered removal of the existing adjustable gastric band and subcutaneous port to alleviate the patient's refractory dysphagia, reflux and regurgitation/vomiting.  The services under review include 43774 (removal of gastric band and port).

Per the health plan denial letter, the prior denial reason was as follows: "This surgery can be approved under the plan clinical criteria when there is surgical complication caused by the initial surgery. This may include heartburn (gastroesophageal reflux, a narrowing in the band (stricture), blockage, leaking at a suture line or enlargement of a part of the stomach (pouch enlargement).  We have not been told you have problems such as these. For this reason, the request is denied as not medically necessary." The reason for appeal is to gain health plan approval for 43774 (laparoscopy, removal of adjustable gastric band and sub cutaneous port).

Yes, the Surgery To Remove Lap Band (procedure code 43774) is medically necessary.
The operation to remove the existing gastric band and subcutaneous port (43774) is medically necessary for this patient.  This procedure is proposed to remove an obstructing gastric band that is causing symptoms of dysphagia, reflux, regurgitation and vomiting.   The patient has previously undergone a band decompression procedure due to symptoms of dysphagia and reflux, yet the obstructive symptoms persist.  Removal of the gastric band will alleviate these symptoms.  The refractory nature of these symptoms despite band decompression and the upper endoscopy study results (dilated esophagus, esophagitis, and esophageal dysmotility) support the medical necessity of code 43774.

Code 43774 is medically necessary, based on the submitted documentation.  Obstructive symptoms of dysphagia, reflux, regurgitation and vomiting are not an uncommon complication of the gastric band procedure.  This operation is a purely restrictive intervention for morbid obesity that was approved for use in the United States by the FDA (United State Food and Drug Administration).  We are now twenty years into the American experience with the adjustable gastric band device, and this experience has revealed that such obstructive symptomatology is a consequence of the gastric band in a significant percentage of patients.

The patient has developed symptoms of partial gastric outlet obstruction (dysphagia, GERD [gastroesophageal reflux disease], regurgitation, and vomiting) related to an existing gastric band.  The submitted records support that that prior band decompression has not alleviated the obstructive symptoms.  The upper endoscopy has identified a surgical complication related to the original surgery (esophageal dilatation, dysmotility and esophagitis).

The proposed gastric band and port removal is medically necessary and consistent with generally accepted standards of care.  This proposed procedure is also consistent with the plan policy.