Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Surgical Procedure on the Stomach (Laparoscopic sleeve gastrectomy) and hospital admission. 
The insurer denied Surgical Procedure on the Stomach (Laparoscopic sleeve gastrectomy) and hospital admission. 
The determination is overturned. 

This is a female patient under consideration for bariatric surgery. She was 64 inches tall and weighed 209 pounds (lbs). This corresponds to a body mass index (BMI) of 35.9 kilograms per square meter (kg/m2). She has comorbid health conditions of hypertension, hyperlipidemia, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder, and panic disorder. She has a history of a stroke and takes Plavix. She is prescribed atorvastatin for hyperlipidemia and Amlodipine for hypertension. Tele-medicine notes provide medical clearance for bariatric surgery. The patient has attempted weight loss with conventional diet programs. 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. Psychological evaluation provides mental health clearance. The patient was referred for nutritional counseling and education and consulted with a registered dietician with follow up (her BMI at this time was 36.6 kg/m2). The patient has the support of her primary care provider for bariatric surgery. The 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 (laparoscopic sleeve gastrectomy with an associated inpatient admission). 
At issue is the medical necessity of the proposed laparoscopic sleeve gastrectomy and inpatient admission. 
Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed laparoscopic sleeve gastrectomy and inpatient admission is medically necessary for this patient. 
This patient has a BMI in excess of 35 kg/m2 with weight related comorbid health conditions that include hypertension, hyperlipidemia, prior deep vein thrombosis (DVT), anxiety, OCD, bipolar disorder, and panic disorder. She has a history of a stroke and takes Plavix. She is prescribed atorvastatin for hyperlipidemia and Amlodipine for hypertension. These weight-related health conditions (hypertension, hyperlipidemia, risk factors for DVT and Stroke) will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical clearance. She has participated with a supervised weight loss program with her primary medical doctor with refractory medically complicated obesity. 
Laparoscopic sleeve gastrectomy is medically necessary for this patient per widely accepted guidelines [1] as her BMI is in excess of 35 kg/m2 in association with weight related illness of hypertension, hyperlipidemia, DVT and stroke. 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.