Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity

Treatment: Sleeve Gastrectomy

The insurer denied coverage for Sleeve Gastrectomy. The denial was upheld.

This patient is a male patient who is being seen for being morbidly obese. His co-morbidities to justify a request for authorization for bariatric surgery is a body mass index (BMI) of 35 to 37.5 and several trials at weight loss including a recent one with an exercise program which he was not compliant with, but yet did lose 8.5 pounds. An Endocrinologist lists him as being a long standing diabetes mellitus type 2 (DMII) patient on insulin, metformin and Victoza with a HbA1c of 6.4 (top normal 6.3), dyslipidemia, and likely fatty metamorphosis of the liver. Bipolar disorder is apparent by the medications he is on. Other co-morbidities not substantiated by the medical records provided to this reviewer include gastroesophageal reflux disease with no reflux on upper gastrointestinal (UGI) series and no evidence of esophagitis on esophagogastroduodenoscopy, as well as vitamin D deficiency, hypertension, obstructive sleep apnea, hypothyroidism, and osteoarthritis. In sum, this is a patient who is morbidly obese with a BMI of 35 to 40 who is a controlled diabetic on insulin, Victoza and metformin with fatty metamorphosis of the liver.

Generally, criteria to qualify for Bariatric surgery include a BMI of 35 or greater associated with co-morbidities such as type II diabetes, hypertension, pulmonary hypertension, cardiomyopathy, coronary artery disease, obstructive sleep apnea, or unremitting lower extremity arthritis. Morbid obesity must be documented for one or more years. Documents must be provided demonstrating that the patient must have participated in a physician-directed weight loss program which is completed within two years of the request lasting anywhere from 3 to 24 months. This program must include supervised exercise, behavior modification, psychiatric support, and medication. Documents must be provided of each visit. Preoperative medical and psychiatric evaluations with surgical clearance must be provided.

Sleeve Gastrectomy with subsequent inpatient hospital stay is not considered medically necessary for this patient.  In this case, the co-morbidities of significance related to morbid obesity are medication controlled Type 2 diabetes, fatty metamorphosis of the liver, and dyslipidemia. This patient has a long history of morbid obesity and failure of trials at weight loss. He is on a multitude of medications and carries a diagnosis of Bipolar disorder. Medical clearance has been provided by his primary care physician. Other listed co-morbidities are not substantiated. Clearance by psychiatry for the bariatric procedure was not provided. Therefore, the Sleeve Gastrectomy with subsequent inpatient hospital stay is not considered medically necessary for this patient. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Per Wolfe, B. M., Kvach, E., & Eckel, R. H. (2016), "Pre-operative psychological assessment is commonly done to identify patients who require preoperative intervention or disqualification altogether. Active substance abuse is a standard contraindication to surgery... Psychological assessment prior to bariatric surgery may identify patients with psychopathology such as major depression"

Per Aminian A. et al, "LSG can significantly improve cardiometabolic risk factors including glycemic status in type 2 diabetes mellitus [T2DM]. Long-term complete remission and "cure" of T2DM, however, occur infrequently."

Per Kassem, M. A., Durda, M. A., Stoicea, N., Cavus, O., Sahin, L., & Rogers, B. (2017), "There are grading systems to predict T2DM remission success and that while the mechanisms supporting this are not fully understood there are a number of hormonal changes that may play a significant role in stabilizing blood glucose levels, improving insulin sensitivity, and regulating appetite which overall have a beneficial effect on T2DM. Restrictive-malabsorptive procedures are known to improve glucose homeostasis, insulin sensitivity, and B-cells secretory function. Bariatric surgery can be considered as a second-line therapy in non-obese diabetic patients."

Based on the above, the medical necessity for the Sleeve Gastrectomy with subsequent inpatient hospital stay is not substantiated.  The insurer's denial is upheld.