Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Pre-elective hospital admission
The insurer denied coverage for pre-elective hospital admission
The denial is overturned.

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does meet the criteria and indications for bariatric surgery. According to MCG Health Inpatient and Surgical Care 27th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (ISC)  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 35 or greater (32.5 or greater in Asian patients); Adult patient has Body Mass Index (BMI) of 30 to 34.9 (27.5 to 32.4 in Asian patients) and ALL of the following: Clinically serious condition related to obesity (such as, type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe lower extremity osteoarthritis, treatment-resistant hypertension); Failure of nonsurgical therapy, as indicated by 1 or more of the following: Inadequately controlled hyperglycemia despite optimal diabetic treatment, Positive airway pressure therapy not effective or not tolerated for obstructive sleep apnea or obesity hypoventilation, Treatment-resistant hypertension, Other serious obesity-related condition insufficiently responsive to nonsurgical treatment (such as nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe osteoarthritis); the patient meets the current revised guidelines as the BMI was greater than 35 and does not require comorbid conditions.

Furthermore, Eisenberg noted in "2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Major updates to the 1991 National Institutes of Health guidelines for bariatric surgery include that Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >= (greater or equal to) 35 Kilogram-Meter Squared (kg/m2), regardless of presence, absence, or severity of comorbidities. The authors noted that "Given the presence of high-quality scientific data on safety, efficacy, and cost-effectiveness of MBS in improving survival and quality of life in patients with BMI >=35 kg/m2, MBS should be strongly recommended in these patients regardless of presence or absence of evident obesity-related co-morbidities. Given the new criteria bariatric surgery in the form of sleeve gastrectomy is recommended and should be approved for this patient. This patient has a BMI over 35 and thus meets the new revised criteria for bariatric surgery and does not require having comorbid conditions present as long as the BMI was greater than 35. Given this scenario sleeve gastrectomy is considered standard of care as noted by MCG as the patient does meet criteria for bariatric surgery.

To summarize, the denial is overturned, and coverage should be provided for sleeve gastrectomy. Based upon the records submitted, the patient does meet criteria for bariatric surgery as the patient does have a BMI greater than 35 and does not require comorbid conditions as the revised criteria by the bariatric societies now recommends bariatric surgery for BMI greater than 35 without comorbid conditions. Based upon these findings the health care plan did not act reasonably and with sound medical judgment. This reviewer is knowledgeable in this condition and the recommended health care services provided.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for pre-elective hospital admission is substantiated.