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

Physician 1The patient is a 36-year-old female with a  body mass index (BMI) of 42.7. In addition the patient has a history of gastroesophageal reflux disease, hiatal hernia and paraesophageal hernia. She is status post laparoscopic Nissen fundoplication and cholecystectomy. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied this request indicating the requested procedure is considered investigational for treatment of the patients morbid obesity.The patient has a documented 20-year history of obesity refractory to conservative diet therapy and presently has symptoms of chest pain, shortness of breath, GERD, and edema directly related to her obesity. It is clear that in terms of weight management in the morbidly obese population, surgery is the only effective therapy. The duodenal switch procedure is designed to avoid dumping syndrome and prevent peptic ulcers. The duodenal switch combines the restrictive gastric pouch with the malabsorptive components of biliopancreatic diversion. It has been reported that the retention of the pylorus results in fewer problems with bowel movements, including dumping syndrome, marginal ulcers, anemia and other complications. The pouch results in excess weight loss of 70-80% with good to excellent success rate of 93% and no difference between patients with BMI scores above or below 50. Duodenal switch is an accepted method of weight loss surgery and is appropriate for treatment of this patients obesity.Based upon the information set forth above, 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 2The patient is a 36-year-old female with a body mass index (BMI) of 42.7. The patient has a history of gastroesophageal reflux disease and paraesophageal hernia. She underwent laparoscopic reduction. The patient now wishes to undergo gastric bypass with duodenal switch for treatment of her morbid obesity. The Health Plan had denied authorization and coverage for the requested procedure on the basis that it is considered investigational for treatment of the patients medical condition. In 2003, Anthone, et al. demonstrated acceptable perioperative morbidity and mortality with duodenal switch. However, at this time there are no randomized, prospective trials establishing the superiority of duodenal switch vs. Roux-en-Y gastric bypass in patients such as this patient with moderate morbid obesity. This patient can be appropriately and effectively treated with Roux-en-Y gastric bypass. The information submitted provides no compelling reason why duodenal switch would be more advantageous for this patient than Roux-en-Y gastric bypass. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 36-year-old obese female with a BMI of 42.7 and multiple comorbidities. She recently underwent Nissen fundoplication for repair of a paraesophageal hernia. She now wishes to undergo a duodenal switch procedure and has completed the appropriate preoperative requirements. The Health Plan has denied coverage for duodenal switch on the basis it is considered investigational for treatment of the patients morbid obesity.The patient is a candidate for a malabsorptive procedure to treat her morbid obesity. There is sufficient evidence in peer-reviewed journals to indicate the duodenal switch procedure is an effective treatment for morbid obesity. Furthermore, the duodenal switch procedure is technically easier in patients such as this patient whose obesity history is complicated by a prior Nissen fundoplication. The duodenal switch is likely to be safer for this patient than standard gastric bypass and should be authorized. 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.