Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe gastroesophageal reflux disease

Treatment: Procedure code 43659 (laparoscopic revision for gastric pouch)

The insurer denied coverage for procedure code 43659 (laparoscopic revision for gastric pouch). The denial is overturned.

This patient is a female with a history of gastric bypass surgery, postgastrectomy
malabsorption, gastroesophageal reflux disease (GERD), gastritis, and H. pylori
infection. The records provided for the review noted that the patient was seen for a reevaluation. She complained of severe gastroesophageal reflux disease and was using 4 pillows at night. Her symptoms were occurring after eating, except for bread, which the patient was able to tolerate. Salads, fruits, and vegetables were causing her severe reflux and she endorsed vomiting and diarrhea as well.

Co-morbidities included a history of abnormal liver function tests, a cough, GERD, H. pylori infection, headaches, hot flashes, iron deficiency, irregular menstrual cycle, lightheadedness, menstrual migraine, night sweats, palpitations, post-gastrectomy malabsorption, status post gastric bypass, severe obesity, and vitamin D deficiency. Her medications at that time consisted of Carafate 1g/10-mL oral suspension, pantoprazole sodium 40 mg oral tablets, chewable Tums, and vitamin D. On physical examination, the patient had mild epigastric tenderness without rebound or guarding. She had positive bowel sounds with no other abnormalities identified. The recommendation at that time was for the continued use of medications and Tums with are commendation for gastric revision.

The physician stated that the patient had tried multiple medications without a significant
Improvement. In addition, she had lost approximately 14 pounds documented as 223 pounds down to 209 pounds. An appeal letter from a separate physician indicated that the patient had undergone a gastric bypass for morbid obesity in the past and was suffering from a worsening of esophageal reflux disease. The latter noted that the results from the upper endoscopy showed severe erosive disease from reflux, and it was recommended that the patient undergo a gastric revision to treat her symptoms.

Gastric bypass revision surgery was recommended for this patient to correct long-term medical complications that developed after a successful gastric bypass surgery, including gastritis and worsening esophageal reflux disease. It was noted that upper endoscopy showed severe erosive disease from reflux and esophagram showed a finding of a very large gastric pouch and the presence of a "candy cane" segment of the Roux limb. Candy cane Roux syndrome in patients who have undergone RYGB refers to an excessively long blind afferent Roux limb at the gastrojejunostomy causing symptoms of post-prandial epigastric pain, nausea, vomiting, and reflux or food regurgitation. Treatment of this complication is revision bariatric surgery. Given her ongoing symptoms, mainly severe reflux, status post gastric bypass, and imaging evidence of a "candy cane" segment of the Roux limb, revision surgery is indicated. Therefore, the procedure code 43659 (laparoscopic revision for gastric pouch) is medically necessary.

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

Based on the above, the medical necessity for 43659 (laparoscopic revision for gastric pouch) is substantiated. The insurer's denial is overturned.