Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Refractory morbid obesity. 
Treatment: 43775 - Re-sleeve gastrectomy and full hospital admission. 

The insurer denied the 43775 - Re-sleeve gastrectomy and full hospital admission. 
The denial is upheld. 

The patient is a woman who underwent laparoscopic adjustable gastric banding a few years prior. This was performed as treatment for morbid obesity. Following this bariatric procedure, the patient had weight loss. However, she developed nausea and vomiting that resulted in the band being removed. Subsequent to band removal, the patient underwent laparoscopic sleeve gastrectomy (performed with a 40F Bougie as a sizing guide). She reportedly was again initially successful with post-surgical weight loss. 

The patient sought evaluation for revisional bariatric surgery to address refractory morbid obesity. The patient had a BMI [body mass index] 39 kg/m2 [kilograms per meters squared]. The patient has comorbid health conditions of sleep apnea, GERD (gastroesophageal reflux disease), asthma, hypothyroidism, rheumatoid arthritis, Sjogren's Disease, and myasthenia gravis. 

The patient has completed an evaluation with upper endoscopy and contrast UGI (upper gastrointestinal series) in addition to medical consultations, nutrition therapy and obesity medicine consultation. The UGI (upper gastrointestinal series) was performed showing a small hiatal hernia and mild reflux. There were post-surgical changes of gastric sleeve without description of anatomic abnormality. Upper endoscopy showed a normal esophagus without mention of esophagitis and mild erythema with a small antral erosion of the stomach. A note does not list antiacid medications among her prescribed medications. 

The patient's TSH (thyroid stimulating hormone) was elevated indicating untreated or undertreated hypothyroidism. A mental health evaluation provides clearance for the proposed revisional bariatric operation. Nutritional consultation was performed. Additional follow up notes were also included. 

The preauthorization request states that the proposed treatment plan for revisional bariatric surgery consisting of revision of the gastric restrictive procedure, repair of hiatal hernia, upper endoscopy and use of the surgical robot. 

The health plan denial letter states that repeat surgery is approvable when there is a problem from the first surgery. The plan states that there is not documentation of a complication of the prior bariatric operation. 

No, the 43775 - Re-sleeve gastrectomy and full hospital admission are not medically necessary. 

The records indicate that this patient has untreated or undertreated hypothyroidism, which can contribute to inadequate weight loss or weight gain post bariatric surgery. Additionally, the contrast UGI (upper gastrointestinal series) and upper endoscopy describe normal and expected post-surgical changes of sleeve gastrectomy without indication of a complication that is amenable to the surgery proposed. There is no documentation to substantiate significant and refractory GERD (gastroesophageal reflux disease), as there is no esophagitis noted on upper endoscopy and the patient was not reported to be taking PPI (proton pump inhibitors) medications at the time of the medical evaluation. The records do not include an objective assessment of GERD (gastroesophageal reflux disease) with pH (potential of hydrogen) study.  Furthermore, even if she does have significant GERD (gastroesophageal reflux disease), the proposed revision of a sleeve gastrectomy will not resolve this condition and may further exacerbate gastroesophageal reflux if the gastric sleeve is further reduced in capacity. 

The records do not document the patient's weight at the time of the previous sleeve gastrectomy procedure. If the proposed revisional operation is offered to treat GERD (gastroesophageal reflux disease), then pathologic esophageal acid exposure must be documented by objective testing.  If the proposed revisional operation is offered to treat refractory morbid obesity, then there must be documentation of a complication that is amenable to the proposed operation.  In this case, there is no documentation of an abnormality of the existing sleeve such as the sleeve being made too large at the time of the initial operation or sleeve enlargement subsequent to the initial operation. 

The documentation in this case does not support that the proposed revisional operation is consistent with guidelines established by the American Society for Metabolic and Bariatric Surgery or the National Institutes of Health. This procedure is not medically necessary, and the related inpatient admission is not medically necessary.