Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 62-year-old female with a body mass index (BMI) of 39. The patient has multiple comorbidities that will be ameliorated or eliminated by bariatric surgery. She requires long-term NSAIDs for osteoarthritis and has failed conventional weight loss therapy. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied coverage for the requested procedure indicating it is experimental.The duodenal switch procedure has a track record greater than 15 years. There are now long-term studies describing equal or greater weight loss with the duodenal switch procedure than with Roux-en-Y. The data reveals duodenal switch results in few incidents of dumping and anastomotic stricture. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This is a 62-year-old patient with a body mass index (BMI) of 39. The patient has tried multiple medical regimens for weight loss without success. There are also multiple comorbid factors, which include hypertension, hypercholesterolemia, and degenerative joint disease. She has undergone a psychological evaluation and has been cleared for weight loss surgery. The patient has requested authorization and coverage for gastric bypass with duodenal switch procedure, which has been denied by the Health Plan.Though the patient has a body mass index less than 40, she has significant comorbidities including hypertension, which necessitate weight loss surgery. In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. Techniques in duodenal switch have been available since the 1980s. With duodenal switch, patients lose weight in the range of 69% to 80%. Complications have been reported to be comparable to other operations. Multiple vitamin deficiencies, mineral deficiencies, bacterial overgrowth issues appear to be comparable or less than other alternative surgeries. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 3: This is a 62-year-old female who is 52 tall and weighs 218 pounds with a body mass index (BMI) of 39 and hypertension, hyperlipidemia, arthritis and plantar fasciitis as listed comorbidities is requesting the duodenal switch method of bariatric surgery as a treatment of her morbid obesity. The Health Plan contends that the duodenal switch operation has not been established as a safe and effective operation. The chart provided for review provides numerous publications, which are peer-reviewed articles. These outline not only the safety of the duodenal switch operation but also its efficacy. Based upon the patients history and current condition it is likely she will have fewer complications and greater benefits from the duodenal switch procedure compared to Roux-en-Y gastric bypass. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.