Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obesity

Treatment: duodenal switch surgery

The insurer is denied coverage for duodenal switch surgery

The denial is overturned. 

This female patient has a history of obesity and gastroesophageal reflux disease (GERD).

Based upon the records provided and Milliman Care Guidelines (MCG) guidelines, the patient does meet the criteria and indications for bariatric surgery.  According  to MCG Health General recovery Care 25th Edition General surgery or procedure GRG SG-GS Surgery or other procedure covered by this guideline is indicated for 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 (body mass index)  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, as indicated by ALL of the following: Patient has tried and has failed to achieve and maintain sufficient weight loss with nonsurgical treatment; Correctable cause for obesity not identified (e.g., hypothyroidism, Cushing syndrome); Patient has demonstrated reliable participation in preoperative multidisciplinary behavior modification program (e.g., preparation for postoperative diet and exercise regimens); Current substance abuse not identified; Not currently pregnant and no planned pregnancy within 18 months of surgery; Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed, and willing to participate and adhere to postoperative instructions); 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 consultation, Preoperative mental health consultation, Nutritional counseling, Exercise counseling, Patient support programs. Thus, based upon these guidelines the patient does meet criteria for revisional surgery especially she had done well following the sleeve but regained her weight during the COVID (Coronavirus Disease) era and because she had COVID as well. She has done nutrition counseling and psych evaluation and was cleared by her medical doctor for revisional bariatric surgery.

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

The carrier's denial of coverage for duodenal switch surgery is overturned.  The medical necessity is substantiated.