Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity. 
Treatment: Surgical Services (All). 

The health plan denied the requested surgical procedure as not medically necessary. 
The health plan's determination is overturned. 

The patient is a woman who is seeking surgical treatment for the condition of super morbid obesity. The patient has a current body mass index (BMI) of 61 kg/m2 (kilogram force per square meter)(65 inches tall) with a weight related comorbid health condition of hypertension. The records indicate that she has been approved for weight loss surgery, but that the specific procedure of single anastomosis duodenoileostomy (SADI) with sleeve gastrectomy has been denied because this procedure is considered to be experimental/investigational by the health plan. 

The patient consulted with her physician for the condition of refractory morbid obesity. The records include documentation of completion of the prerequisite multidisciplinary bariatric evaluation. A mental health evaluation was completed with clearance for the proposed bariatric surgical intervention. The patient received a nutritional consultation  There is documentation of her participation with a supervised weight loss program.
The submitted records include a letter of support from the patient's primary care provider. 

At issue is the medical necessity for the requested surgery and inpatient stay. 

The health plan's determination is overturned, in whole. 

Yes. The submitted records do support the medical necessity of the proposed single anastomosis duodenoileostomy and the associated inpatient admission for this patient. In this case the proposed procedure (SADI with sleeve gastrectomy and inpatient admission) is a medically necessary treatment for the documented condition of medically complicated super morbid obesity with a BMI of 61 kg/m2 and is supported by the most recent guidelines published by the American Society for Metabolic and Bariatric Surgery (ASMBS).[1] The proposed treatment in this case is the loop duodenal switch procedure also known as the single anastomosis duodenal switch or single anastomosis duodenoileal bypass with sleeve gastrectomy. This procedure is proposed as a bariatric operation to achieve weight loss and ameliorate comorbid health conditions. 
This patient has the diagnosis of super morbid obesity with a BMI in excess of 60 kg/m2 and comorbid health conditions of hypertension. She has successfully completed a comprehensive multidisciplinary bariatric evaluation with medical, mental health, nutritional, and surgical evaluations. There is no medical or mental health contraindication to the proposed procedure for this patient. 

This procedure is provided in accordance with generally accepted standards of medical practice. It is clinically appropriate and considered effective for the patient's condition. It is not for the convenience of anyone and is not more costly that alternative equally effective treatment. 

An inpatient level of care is consistent with the standard of care regarding performance of this bariatric operation. This period of inpatient stay allows for provision of intravenous (IV) fluid, analgesia, antiemetics, and appropriate monitoring during the period of diet advancement following gastric resection. The intensity of service associated with the management of the bariatric surgical patient (particularly a patient with a BMI in excess of 60 kg/m2 and related comorbid health conditions as in this specific case) warrants an inpatient designation and is consistent with the standard of medical/surgical care. A 2-day period of inpatient confinement is consistent with bariatric surgical standards for this patient. A lower level of care such as observation, rather than inpatient care, could jeopardize the health of this patient.