Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity.

Treatment: procedure code 43644, weight loss surgery (sleeve gastrectomy) and 1 inpatient day.

The insurer denied coverage for procedure code 43644, weight loss surgery (sleeve gastrectomy) and 1 inpatient day.

The denial is upheld.

As per the medical records, this patient has a history of morbid obesity, hypertension (HTN), hyperlipidemia (HLD), fatty liver, insulin dysmetabolic syndrome, gastroesophageal reflux disease (GERD), anxiety and depression. The patient was seen on by his physician who noted that the patient attempted multiple diets over the years and though he has been able to lose modest amounts of weight, he has never been able to sustain it. His body mass index (BMI) is 36.7. He noted the patient met the National Institute of Health (NIH) criteria for bariatric surgery and he recommended a laparoscopic Roux-en-y gastric bypass. He was seen again later. He recommended starting the patient on Saxenda.

Initial nutritional assessment was done. His BMI at that time was 33.9.  The patient was counseled and agreed to preop nutritional guidelines. The plan was for medically supervised diet for six months. The patient was seen again for reconsult. The weight was noted to be 239. The patient started Saxenda.  The patient was seen for reconsult where it was noted that the weight was now 235. He continued on preop weight loss plan.  
The patient was seen again by nutrition where the BMI was 32.1 and weight was 230.  
The patient was seen on another occasion with the weight now 229.6 and BMI of 32. This was his #6 supervised weight loss visit. It was noted that he has lost 30.3 pounds since he started Saxenda. The patient was seen again by nutrition where his weight was now 219 and a BMI of 30.5.

Based upon the records provided 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 25th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy 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: Patient has BMI of 40  or greater, or  adolescent patient (13 to 17 years of age) has BMI of 40 (or 140% (percent) of the 95th percentile in an age and sex matched growth chart) or greater, or Patient has BMI of 35 or greater and clinically serious condition related to obesity.

This patient has a BMI less than 35 (currently approximately 30) and does not have co morbidities which would justify bariatric surgery. The patient has lost weight on a supervised diet and there is no indication for weight loss surgery.  Thus, the patient does not meet MCG criteria and should not have bariatric surgery.

The health care plan did act reasonably and with sound medical judgment as the patient has a BMI of approximately 31. The starting BMI of 36 is not justification now for bariatric surgery. The patient was able to lose weight and has done an excellent job. 

The insurer's denial of coverage for procedure code 43644, weight loss surgery (sleeve gastrectomy) and 1 inpatient day is upheld. Medical Necessity is not substantiated.