Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Obesity
Treatment: Inpatient surgical procedure on the stomach for weight loss
The insurer denied coverage for the inpatient surgical procedure on the stomach for weight loss.
The denial is overturned.

This is a patient with a history of diabetes, obstructive sleep apnea (OSA), severe obesity, and asthma. He presented to the General surgeon's office for a bariatric consultation. His body mass index (BMI) was 43. It was noted that years ago the patient was considering bariatric surgery but was not cleared a few weeks before surgery by his endocrinologist. He has tried multiple weight loss modalities in the past. He is seeking surgery for improvement of his overall heath and to mitigate the impact of future medical comorbidities. Risks and benefits were discussed including adherence to a regimen of diet and exercise regimen.

After reviewing the toxicology screening, a doctor wanted to confirm that there is no current substance abuse identified and the patient is cleared to have bariatric surgery.

The patient was seen by pulmonary, where it was noted the patient was using continuous positive airway pressure (CPAP) every night, and it was noted that there was no absolute contraindication to bariatric surgery. The patient was seen by cardiology for clearance, and he noted no cardiac contraindications for surgery.

According to Milliman Care Guidelines (MCG) guidelines, the patient does meet the criteria and indications for bariatric surgery. According to MCG Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: adult patient has BMI of 40 or greater, or adolescent patient has BMI of 40 (or 140% [percent] of the 95th percentile in an age and sex matched growth chart) or greater, or adult Patient has BMI of 35 or greater and 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), or adolescent patient has BMI of 35 (or 120% of the 95th percentile in an age and sex matched growth chart) or greater and a clinically serious condition related to obesity (e.g., type 2 Diabetes, obstructive sleep apnea, nonalcoholic steatohepatitis, ... Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed and willing able to participate and adhere to postoperative requirements); No current untreated eating disorder; No serious untreated or uncontrolled medical, psychiatric, psychosocial or cognitive condition that would interfere with adherence to postoperative instructions, and self-care; Patient is receiving treatment in multidisciplinary program experienced in metabolic surgery that can provide ALL of the following: Surgeons experienced with procedure, Preoperative medical health consultation, Nutritional counseling, Exercise counseling, Patient support programs. This patient has a BMI that has been consistently greater than 40 and, as such, does meet the criteria to have bariatric surgery. In addition, the patient did have a negative toxicology screen. The patient was also cleared by cardiology, pulmonary, psychology and as well as by nutrition. Therefore, the patient has met the guidelines, and the insurer is wrong for denying bariatric surgery for this patient.

The denial is overturned, and coverage should be provided for sleeve gastrectomy as well as inpatient stay. Based upon the records submitted, it appears that the patient does meet criteria for bariatric surgery. I do believe that based upon these findings the health care plan did not act reasonably and with sound medical judgment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient surgical procedure on the stomach for weight loss is overturned. Medical Necessity is substantiated.