Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Surgical Services (All). 
The insurer denied Surgical Procedure on the Stomach and Inpatient Stay. 
The denial is upheld. 

This patient is a female under consideration for bariatric surgery. She was 63 inches tall and weighed 217 lbs. This corresponds to a body mass index (BMI) of 38.4 kilograms (kg)/meter squared (m2). She has no reported weight related comorbid health conditions per the bariatric surgical consultation. A sleep medicine evaluation did not identify obstructive sleep apnea. She is prescribed no medications presently. The patient has attempted weight loss with dietary efforts as are detailed in the surgical and nutritional evaluations. She had not been successful with significant sustained weight loss.
The patient sought evaluation for bariatric surgical consultation. The records indicate that she was entered into a multidisciplinary bariatric program. Psychological evaluation provides mental health clearance. She has consulted with a dietician and has received nutritional counseling and education. The alanine aminotransferase (ALT) is slightly elevated at 37 with a normal aspartate aminotransferase (AST) and bilirubin. Following this evaluation and because of persistent morbid obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy and related inpatient admission).
At issue is the medical necessity of Surgical Procedure on the Stomach and Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Surgical Procedure on the Stomach and Inpatient Stay is not medically necessary for this patient.
The requested service, (laparoscopic sleeve gastrectomy[LSG] and inpatient admission), is not medically necessary for this patient based on the current standard of care and evidence-based literature.  The patient does not meet the widely accepted National Institute of Health (NIH) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure (BMI of 38.4 kg/m2 without clinical documentation of comorbid conditions). The submitted records do not include clinical data to support the presence of a weight related illness. The submitted sleep evaluation did not confirm the diagnosis of sleep apnea. While the patient has been evaluated by a multidisciplinary bariatric program and is well informed about the necessary follow-up and dietary changes, her condition does not satisfy the weight/BMI/weight related comorbidity requirements that are generally accepted to select patients for bariatric surgery. [1]
This patient's condition does not satisfy The American Society for Metabolic and Bariatric Surgery (ASMBS) and National Institutes of Health (NIH) weight/BMI criteria for consideration for bariatric surgery including LSG as she has a documented BMI between 35-40 kg/m2 without weight-related comorbid health condition. LSG is not medically necessary for this patient based on the submitted clinical documentation and is not known to be health beneficial for her based on published literature. [1,2,3,4] It is the standard of care that a patient considering bariatric surgery have a BMI between 35-40 kg/m2 and have an associated weight related medical condition that is expected to improve or resolve with weight loss or have a BMI of at least 40 kg/m2. [ 1,2 4,7] 
In this case sleeve gastrectomy and inpatient admission is not in accordance with generally accepted standards of medical practice, is not clinically appropriate or considered effective for the member's disease and is not proven to be more medically effective than any standard nonsurgical care and treatment.
Therefore, the requested health service/treatment of Surgical Procedure on the Stomach and Inpatient Stay is not medically necessary for this patient.