Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity.
Treatment: Bariatric Surgery.

The insurer denied coverage for bariatric surgery.  The denial is upheld.

This is a patient with a history of prediabetes, asthma, obesity and epilepsy. In a note from the provider, he recommended that the patient undergo bariatric surgery. 

The provider noted that the patient has suffered from morbid obesity for over 4 years. At the current weight of 282 pounds and 5 ft (feet) 10.5 inches, he has morbid obesity and has a body mass index (BMI) of 39.89. He has been suffering from several major health problems due to his obesity, including asthma, Vitamin D deficiency, snoring, and Iron deficiency anemia. Substantial weight loss is required to alleviate these health problems. Despite multiple attempts at dieting and exercise the patient has failed to achieve long term weight loss. He has been counseled repeatedly on the risks of developing further co-morbid conditions due to severe obesity. The provider strongly feels the only reasonable alternative is weight loss surgery.

Preoperative medical assessment was included and reviewed. HbA1C (glycated hemoglobin) was 6.1 which is considered prediabetes. Cardiology noted that the patient had a normal EKG (electrocardiogram) and a 2-D (dimensional) echo on showed mild LV (left ventricular), mild LA (left atrium) enlargement, and mild left ventricular dilation with an EF (ejection fraction) of 65% (percent). The doctor feels that the patient is asymptomatic and has low to moderate risk for perioperative event from surgery. He was cleared from a cardiovascular point of view but needs to be cleared by hematology for mild anemia. Sleep study done indicated the patient did not have significant obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 3.3 events per hour.

Based upon the records and Milliman Care Guidelines (MCG) guidelines, the patient does not meet the criteria and indications for bariatric surgery. 

According  to MCG Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC)  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: adult patient has BMI of 40 or greater (37.5 in Asian patients), 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 adult Patient has BMI of 35 or greater (32.5 in Asian patients) and clinically serious condition related to obesity (e.g. type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis, difficult to control hypertension), or adolescent patient (13 to 17 years of age) has BMI of 35 (or 120% of the 95th percentile in an age and sex matched growth chart) or greater and a clinically serious condition related to obesity (e.g. type 2 Diabetes, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudotumor cerebri, Blount disease (tibia vara), slipped capital femoral epiphysis), or Adult patient has BMI of 30 or greater (27.5 in Asian patients) with type 2 diabetes mellitus with inadequately controlled hyperglycemia despite optimal medical treatment (e.g. oral medication, insulin);  Patient is candidate for bariatric surgery as indicated by ALL of the following: Patient has tried and has failed to achieve and maintain significant weight loss with nonsurgical treatment, Correctable cause for obesity not identified (e.g., hypothyroidism, Cushing syndrome), Patient has demonstrated reliable participation in preoperative multidisciplinary behavior modification program (e.g., preparation for postoperative diet and exercise regimens); Current substance abuse not identified; Not currently pregnant and no planned pregnancy within 18 months of surgery; Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed and willing able to participate and adhere to postoperative requirements); No current untreated eating disorder; No serious untreated or uncontrolled medical, psychiatric, psychosocial or cognitive condition that would interfere with adherence to postoperative instructions, and self-care;  Patient is receiving treatment in multidisciplinary program experienced in metabolic surgery that can provide ALL of the following:  Surgeons experienced with procedure, Preoperative medical consultation, Preoperative mental health consultation, Nutritional counseling, Exercise counseling, Patient support programs. 

This patient has reportedly a BMI of 39 (documented once), and in addition he does not have the co-morbidities meeting bariatric surgery criteria. Furthermore, there is no evidence that he has participated in a multidisciplinary program. There is no mental health provider evaluation, no nutrition consultation and no evidence of following a weight reduction program. As such, he does not meet the criteria for bariatric surgery.

Based on the above, the insurer's denial must be upheld.   The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for bariatric surgery services is not substantiated.