Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea, hyperlipidemia, joint pain, GERD (gastroesophageal reflux disease) and peripheral edema. 
Treatment: Weight Loss Surgery (code 43775) And Inpatient Hospital Admission. 

The insurer denied the Weight Loss Surgery (code 43775) And Inpatient Hospital Admission. The denial is overturned. 

This patient is a woman under consideration for bariatric surgery. She is 62 inches tall and weighs 196 lbs (pounds). This corresponds to a body mass index (BMI) of 36 kg (kilograms)/m2 (meters squared). Her obesity related comorbid conditions include sleep apnea for which she is prescribed CPAP (continuous positive airway pressure) (in addition to weight loss), hyperlipidemia, joint pain, GERD (gastroesophageal reflux disease) and peripheral edema. The patient has a long history of prior weight loss efforts that have not been successful. While she has attempted to lose weight with conventional programs, she has remained with medically complicated morbid obesity. 

The patient sought evaluation for evaluation for bariatric surgery. She was entered into a multidisciplinary bariatric program. She has consulted with a psychologist. The patient has been cleared for bariatric surgery from a mental health standpoint. The patient consulted with a dietician and was counseled and educated on the nutritional changes necessary with sleeve gastrectomy.  She followed a supervised weight loss program. The patient also has completed cardiology, pulmonary, and sleep evaluations. A sleep study confirms the diagnosis of obstructive sleep apnea for which CPAP (continuous positive airway pressure) has been prescribed. 

Following this evaluation and because of persistent medically complicated obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy). 

The health plan rationale for denial was that there is not documentation a BMI (body mass index) of more than 40 kg (kilograms)/m2 (meters squared) or a BMI (body mass index) of at least 35 kg (kilograms)/m2 (meters squared) with a required comorbidity.  The denial letter states that the patient's comorbid health conditions do not warrant bariatric surgery in the setting of a BMI (body mass index) of between 35 to 39.9 kg (kilograms)/m2 (meters squared). 

Yes, sleeve gastrectomy and the associated inpatient admission are medically necessary based on the submitted clinical data and generally accepted standards of care. 

Laparoscopic Sleeve Gastrectomy (LSG) will be more beneficial than any alternative non-surgical weight loss program for the treatment of this patient's medically complicated obesity. There are numerous published reports in the peer-reviewed literature describing outcomes in patients after sleeve gastrectomy. There is greater than five-year follow up data that is available to support the safety and efficacy of the sleeve gastrectomy procedure. The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 kg (kilograms)/m2 (meters squared) and excess weight loss ranging from 33% to 83%. 

Comorbidity resolution 12 to 24 months after sleeve gastrectomy has been reported numerous studies. These studies include five-year data that demonstrates resolution rates of diabetes, hypertension, hyperlipidemia, and sleep apnea after sleeve gastrectomy that are comparable to results of other restrictive procedures. 

With supportive five-year data and an affirmative position statement from the ASMBS (American Society for Metabolic and Bariatric Surgery), individual consideration should be given to selected patients who are contemplating this surgical approach. Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the patient's disease, is not deemed to be cosmetic or unproven, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the patient or physician. 

The health plan rationale for denial was based on the contention that the patient must have a BMI (body mass index) of at least 40 kg (kilograms)/m2 (meters squared) or a BMI (body mass index) between 35-39.9 kg (kilograms)/m2 (meters squared) with weight related comorbidity. The requirement that a patient have weight related comorbid illnesses of a certain arbitrary severity is not consistent with nationally recognized standards. This patient has significant weight related illness (sleep apnea, hyperlipidemia, joint pain, GERD [gastroesophageal reflux disease] and peripheral edema) that will respond favorably to the weight loss anticipated with sleeve gastrectomy. 

The proposed sleeve gastrectomy is medically necessary for the patient and is consistent with the standard of care. 

The requested service laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient for the following reasons: 1) The patient meets the widely accepted NIH (National Institutes of Health) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG (Laparoscopic Sleeve Gastrectomy) procedure (BMI [body mass index] of 36 kg [kilograms]/m2 [meters squared], weight related comorbid conditions that include sleep apnea, hyperlipidemia, joint pain, GERD [gastroesophageal reflux disease] and peripheral edema, failed nonsurgical efforts to promote weight loss). 2) The patient has been evaluated by a multidisciplinary bariatric program.  She has been counseled regarding the necessary post-surgical nutritional and lifestyle changes and she has been granted mental health clearance. 3) The LSG (Laparoscopic Sleeve Gastrectomy) procedure is not unproven.  It has garnered the support of ASMBS guidelines and has proven efficacy and weight loss comparable to other bariatric procedures. 

This patient is an appropriate candidate for LSG (Laparoscopic Sleeve Gastrectomy). She has been evaluated by a multidisciplinary bariatric program with nutritional and psychological consultations and she satisfies ASMBS (American Society for Metabolic and Bariatric Surgery) and NIH (National Institutes of Health) weight/BMI (body mass index) criteria for consideration for bariatric surgery including LSG (Laparoscopic Sleeve Gastrectomy).  LSG (Laparoscopic Sleeve Gastrectomy) is medically necessary for this patient and this procedure is likely to be health beneficial for her.