Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Obesity.
Treatment: Surgical services-Bariatric surgery.
The health plan denied the proposed surgical procedure as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This patient is under consideration for bariatric surgery. She was 59 inches tall and weighed 195.6 pounds (lbs.) This corresponds to a body mass index (BMI) of 39.5 kilograms per meters squared (kg/m2). She has comorbid health conditions of gastroesophageal reflux disease (GERD) and sleep apnea for which continuous positive airway pressure (CPAP) has been prescribed. The patient has attempted weight loss with conventional weight loss programs as detailed in the surgical assessment. Unfortunately, she has 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. The psychological evaluation provides mental health clearance. The patient consulted with a registered dietician and received nutritional counseling and education with follow up. The patient transiently lost 50 lbs. during this period of time, but subsequently gained weight. Her thyroid stimulating hormone (TSH) was normal. Following this evaluation and because of persistent medically complicated obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).
The laparoscopic sleeve gastrectomy and associated hospital admission is medically necessary in this case per accepted guidelines for the care of medically complicated obesity. This type of surgery is typically performed in the hospital with an inpatient level of care. This inpatient status provides for surgical treatment and the medically necessary peri- and post-surgical care, intravenous fluid, antiemetics during diet progression and appropriate post-surgical monitoring. The intensity of service associated with perioperative bariatric care warrants an inpatient designation. Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 kg/m2 in association with weight related illness of  GERD and sleep apnea. There is serial documentation of active participation in a nonsurgical weight reduction regimen over a period of one year. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical evaluation with lab data and electrocardiogram and is felt to be an acceptable candidate. Finally, the treatment plan includes pre and post op dietary / nutritional counseling. From the available data it can be expected that laparoscopic sleeve gastrectomy and inpatient admission would be health beneficial for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed bariatric operation.