Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Weight loss surgery correction (procedure codes 44238 and 43845) and inpatient stay. 
The insurer denied coverage for weight loss surgery correction (procedure codes 44238 and 43845) and inpatient stay. 
The denial is upheld. 

As per the progress note, the patient has morbid obesity. The patient is interested in revisional bariatric surgery. The patient's past medical history includes morbid obesity and hypertension (HTN). The patient's surgical history includes kidney stones and gastric sleeve (date not specified). The patient's body mass index (BMI) is 38.31. Options were discussed with the patient with the plan for intestinal bypass. The provider did note that the patient had a weight of 250 and lost down to 145 but had gained weight with pregnancy and has had HTN since the pregnancy. 

The patient had post sleeve follow up on where it was noted the patient was to have an esophagogastroduodenoscopy (EGD) the following day. The patient's BMI was 38.22. The patient underwent EGD and was found to have a healthy appearing mucosa from the sleeve gastrectomy. The exam was otherwise without abnormality. 
 
The patient was seen in follow-up and had a BMI of 36.37 with HTN still noted. 

Based upon the evidence provided, it is agreed that this patient had a prior sleeve gastrectomy and had lost weight down to 145 pounds but regained the weight after a pregnancy. The patient had an EGD which was unremarkable. The patient did not have an upper gastrointestinal series (UGI) to show pouch dilation or any other complication that would then dictate the need for revisional surgery. The patient did undergo an evaluation by the surgeon and psych. There is no evidence of a multi-disciplinary approach in terms of nutrition follow-up. In fact, there are no records provided following the original sleeve gastrectomy. There is no indication of compliance to a post sleeve diet as well. In fact, the patient is hypertensive repeatedly which would go along with noncompliance. Thus, this reviewers agrees with the insurer at this point in time and not approve the revisional surgery as there is no clear mechanical failure of the prior surgical reconstruction. There is no evidence of bowel perforation, leakage, intestine or stomach blockages or surgical staple line failure. Thus, there is no indication as it does not appear that a complication was seen as the cause for weight regain. 

Brethauer et al noted in "Systematic review on re-operative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force" in Surg Obes Relat Dis 2014, that re-operative bariatric surgery has become a common practice in many bariatric surgery programs. A task force was convened to review the current evidence regarding re-operative bariatric surgery. They noted that the evidence regarding re-operative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. They concluded that the indications and outcomes for re-operative bariatric surgery are procedure-specific, but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications. Conversion procedures are intended for patients who experience satisfactory weight loss and corresponding resolution of co-morbidity after laparoscopic adjustable gastric banding (LAGB) and then experience subsequent weight gain and or co-morbidity recurrence without a significant anatomic abnormality identified. Given that no details were provided regarding her prior sleeve and weight loss, approval for revisional surgery cannot be given. 
	
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 surgery (procedure codes 44238 and 43845) and inpatient stay to be provided on a date to be determined is not substantiated.