Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Revisional weight loss surgery
The insurer denied coverage for revisional weight loss surgery.
The denial is upheld.

Based upon the evidence provided, the reviewer has to agree with the insurer as this patient had a prior operation for similar symptoms of vomiting. It is unclear as no records were provided on what was done at the operation and if any revisions were made. The patient had prior to this operation an upper gastrointestinal series (UGI) which did not show obstruction or stricture. The repeat surgery that was done appears to be lysis of adhesions and an exploratory laparotomy and may not have been a revision of the sleeve gastrectomy. As noted in the studies from the Esophagogastroduodenoscopy (EGD) demonstrated an outpouching posterior to the lumen of the sleeve that travels 5 centimeters (cm) distal to the gastroesophageal (GE) junction was seen as well as a 1-2 cm hiatal hernia. The fundus appeared to have a retained fundus versus outpouching from prior band. However, there was no evidence of obstruction otherwise. An UGI had been performed and showed no evidence of contrast leak or obstruction but did show contrast pooling in the proximal stomach just beyond the GE junction. From these studies it is unclear if there is a stricture. As such, this reviewer would have to agree with the insurer at this time, because as noted by the insurer revision of prior weight loss surgery is covered when there is a clear mechanical failure of the prior surgical reconstruction. 

It should be noted that complications do arise that require revision of the sleeve as noted. For example, Ellsmere JC noted "Late complications of bariatric surgical operations" in UpToDate that "The most common complications of Sleeve Gastrectomy (SG) include bleeding, narrowing or stenosis of the stoma, and leaks." With regards to stenosis, he noted that "narrowing or stenosis can create gastric outlet obstruction. The presentation varies depending on the severity of the obstruction and can include dysphagia, vomiting, dehydration, and the inability to tolerate an oral diet. The gastroesophageal junction and the incisura angularis are the two most common areas where stenosis occurs, and this can be diagnosed by an upper gastrointestinal series. The most common reasons for the development of narrowing or stenosis are over-sewing the staple line and using a bougie that is too small. Management of stenosis primarily consists of endoscopic dilation. If the area of stenosis is too long, surgical intervention may be necessary with conversion to a Roux-en-Y gastric bypass (RYGB), gastric stricturoplasty, or resection with gastrogastrostomy." In this case there was no evidence of obstruction on the UGI or endoscopy. Finally, Ellsmere noted that reflux can also be considered a complication of sleeve. He noted that "Gastroesophageal reflux after SG presents with classic symptoms such as burning pain, heartburn, and regurgitation. It can occur as an early and late complication. The first-line treatment is anti-reflux medical therapy. Gastroesophageal Reflux Disease (GERD) unresponsive to anti-reflux medical therapy with no clear anatomic abnormalities, such as stoma stenosis or a hiatal hernia, can be effectively treated by conversion to RYGB." If vomiting is from reflux, it should be treated with anti-reflux medical therapy and not repeat revisional surgery as is being recommended. Therefore, given this the reviewer agrees with the insurer that there is no indication for revisional surgery of the sleeve at this time. However, with further documentation and testing, revisional surgery could be indicated.
	
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for revisional weight loss surgery is not substantiated.