Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: revision of a prior weight loss surgery

The insurer denied coverage for revision of a prior weight loss surgery

The denial is overturned.

As per the medical records, this patient was seen with a history of previous gastric bypass followed by multiple hernia repairs, who presented for bariatric consult and is interested in revision surgery. She reported she gained a lot of weight during COVID (coronavirus) and in the last few years. She reported her weight was 230 pounds a year ago and now weighs 257 pounds. She has the capacity for 2 slices of pizza. She takes Keppra for seizures and Lexapro. She had lengthy discussion on how she will only be successful with further weight loss surgery. The patient understood the need for lifestyle change. The plan was esophagogastroduodenoscopy (EGD), upper gastro duodenoscopy (UGI) and blood work. The patient was to start seeing the dietician and will have a consult with psychiatry. The patient was seen again via telehealth for follow up. The provider noted the patient had a bone density scan which was normal. Her body mass index (BMI) was 46 and it was noted she has tried to lose weight with diet modifications. It was noted that she has recidivism, but that workup does show dilated anastomosis and technical reasons why she has had recidivism following bypass approximately years ago.

According to MCG Health General Recovery Care 25th Edition General surgery or procedure) Clinical Indications for Procedure Surgery or other procedure covered by this guideline is indicated for 1 or more of the following: "Gastrectomy with biliopancreatic diversion (with or without duodenal switch) needed, as indicated by 1 or more of the following: Patient had prior alternative bariatric procedure (e.g., laparoscopic sleeve gastrectomy) with need for revision biliopancreatic diversion, as indicated by ALL of the following: Revision procedure appropriate, as indicated by 1 or more of the following: Less than 50% (percent) of excess weight lost 1 year or longer after prior bariatric procedure, Regain of more than 25% of excess weight lost, BMI greater than 35 and persistence of a clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudotumor cerebri, severe osteoarthritis, difficult to control hypertension) 1 year or longer after prior bariatric procedure, and Patient remains candidate for bariatric surgery...

This patient went through a multidisciplinary program and does meet the National Institute of Health (NIH) requirements for bariatric surgery. 

In addition, there are papers that note the utilization of the dudoneal switch to treat morbid obesity in a case such as this.  Alexa et al., noted "Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel" in Surg Obes Relat Dis "As a second-stage procedure, BPD/DS [biliopancreatic diversion / duodenal switch] is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%)."  Thus, the procedure that is being requested is reasonable and the patient does meet the guidelines for bariatric surgery in the form of duodenal switch.

Revision of a prior weight loss surgery is medically necessary as the patient had prior bariatric surgery and did lose approximately 120 pounds only to regain the weight. In addition, she now a dilated anastomosis leading to increased capacity. Thus, she has done well from her bariatric surgery and deserves as noted by the provider another chance with revision surgery.  The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for revision of a prior weight loss surgery is overturned. Medical Necessity is substantiated.