Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm (centimeter) common channel) to limit absorption code 43845, and one inpatient day

The insurer denied coverage for partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption code 43845, and one inpatient day

The denial is overturned 

As per the medical records, this patient was seen with a history of previous sleeve gastrectomy. She lost 80 pounds with that procedure and achieved a nadir weight of 220 pounds. The patient stated that she did not feel much restriction from her gastric sleeve and her weight loss plateaued within her first post-operative year. She regained all of it over the past several years. She admitted to being non-compliant with her diet and not exercising. She currently has a body mass index (BMI) of 47. The surgeon felt she met the National Institute of health (NIH) criteria for bariatric surgery and would like to have a laparoscopic modified duodenal switch. 

The patient was seen for psychological screening. She noted the patient was under the care of a physician who plans to do bariatric surgery. She noted that the patient had a sleeve and lost 100 pounds over the next several years. She has had more frequently feelings of being hungry, leading to larger portions of food at mealtime and snacking in between meals. The patient's growing health concerns and desire to resume her weight loss efforts prompted her to consult a bariatric physician to discuss her candidacy for bariatric revision surgery. The patient denied ever being treated for an emotional problem. The patient was therefore recommended as a candidate for bariatric revision surgery.

The doctor noted that the patient suffers from morbid obesity with a BMI of 47. He noted that she made countless unsuccessful attempts at weight loss employing a variety of diets, exercise and health plans. She has utilized calorie counting, slim fast, nutrition supervised program, and Trim Spa.  Despite the initial weight loss with each of these methods her weight continued to increase and remains significantly elevated. The patient suffers from hypertension (HTN), fatty liver and gastroesophageal reflux disorder (GERD). The provider is requesting authorization for surgical intervention for the treatment of morbid obesity.

Based upon the records provided, the patient meets criteria for revision of her sleeve with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption code 43845, and one inpatient day. The patient is morbidly obese and did have a prior sleeve in which did lead to weight loss. However, over time the patient regained all her weight. She has gone through a rigorous multidisciplinary program and she requires revision surgery to help her improve her health and lose this weight.

Alexa et al noted "Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel" in Surg Obes Relat Dis "As a second-stage procedure, BPD/DS (bilopancreatic diversion/ duodenal switch) is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% [percent] agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%)."  

Sorribas et al noted "Experience in biliopancreatic diversion with duodenal switch: results at 2, 5 and 10 years" in Cir Esp (Engl Ed) that "Duodenal switch (DS) is considered one of the most effective techniques to achieve weight loss and reduce comorbidities in patients with morbidly obesity. Direct DS is a safe and effective technique in patients with a BMI between 45 and 55 kg/m2 (kilogram per square meter). Weight loss is maintained with a low rate of revision surgery." 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Therefore, denial is overturned.

The insurer's denial of coverage for partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption code 43845, and one inpatient day is overturned. Medical Necessity is substantiated.