Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional - Morbid Obesity. 
Treatment: Esophagogastroduodenoscopy (EGD). 
The insurer denied EGD. 
The denial is overturned. 

This patient is a male who is requesting for an upper endoscopy as a screening evaluation prior to bariatric surgery (sleeve gastrectomy). His body mass index is 47.6 kilogram (kg)/square meter (m2). He has a history of passing blood per rectum while using aspirin. He has comorbid health conditions of hypertension, atrial fibrillation, sleep apnea and hyperlipidemia. Upper endoscopy was performed and identified Grade A esophagitis. 

The health plan denial letter states that an esophagogastroduodenoscopy (EGD) can be approved under the plan clinical criteria for people aged 18 and over when used to diagnose certain conditions such as heartburn after 2 months of treatment, persistent vomiting, feeling of fullness when age 50 or older, internal bleeding, problems during weight loss surgery or suspicion of cancer or blockage. The denial letter states that these conditions do not exist in this case. 

At issue is the medical necessity of EGD. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of EGD is medically necessary for this patient.
Pre-surgical endoscopy is medically necessary for this patient. Bennett et al evaluated the role for pre-surgical upper endoscopy in a meta-analysis that comprised 12,261 patients with a mean (SD) age of 40.5 (1.3) years and body mass index of 46.3 (1.5) kg/m2. The majority of patients (77.1%) were female. The proportion of EGDs resulting in a change in surgical management was 7.8%. Changes in medical management were seen in 27.5%. 

Published data on the role for pre-surgical endoscopy supports that this evaluation should be a covered benefit for patients undergoing bariatric surgery. Obesity is an important risk factor for several digestive diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia (HH), Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, non-alcoholic fatty liver disease (NAFLD), cirrhosis, and hepatocellular carcinoma. Most of these diseases are observed up to 2-3 times more frequently in obese patients than in normal weight individuals and may be asymptomatic. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal (GI) findings, such as a large HH or Barrett's esophagus, are detected preoperatively. The published guidelines of the European Association for Endoscopic Surgery state that esophagogastroduodenoscopy (EGD) or upper-GI series is advisable for all bariatric procedures and strongly recommended for gastric bypass patients [Roux-en-Y gastric bypass (RYGB)]. Similarly, the recently published guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommended that EGD should be performed in all symptomatic patients undergoing bariatric surgery and considered in all candidates.
Therefore, the requested health service/treatment of EGD is medically necessary for this patient.