Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid obesity

Treatment: Procedural code 43845 duodenal switch

The insurer denied coverage for procedural code 43845 duodenal switch.

The denial is overturned.

As per the medical records, this patient has a history of morbid obesity and gastroesophageal reflux disease (GERD), status post (s/p) lap band surgery. As per the office telehealth, the patient lost 70 pounds after the operation but over time the band became less effective and eventually, she regained all of her weight back. This occurred despite the band being tight, making it difficult for her to eat solid food. The patient suffers from GERD. Her current body mass index (BMI) is 48.9. The patient wants to have the laparoscopic (lap) band removed and have a different bariatric procedure to help her lose weight. As a result of her weight regain, she experienced infertility and miscarriages. The provider noted that this clearly represents a failure of the lap band. She meets the National Institute of Health (NIH) criteria for bariatric surgery and would like to have her band removed and have a lap modified duodenal switch.

The procedure is one of several that can be done in this patient as a revision of the lap band. As noted by Lim in "Bariatric procedures for the management of severe obesity: Descriptions" in UpToDate 2022 for patients who fail the band or who have complications from it that require removal, there are several conversion options that have been published. The band can be replaced, or it can be converted to a sleeve gastrectomy (SG), a Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD/DS). Thus, there is significant literature to support improved health outcomes after the duodenal switch whether a single or double anastomosis and the insurer is incorrect to state that it is experimental.

The adverse risks do not appear to be increased over standard treatment services. In fact, Spinos, et al noted in "The Effectiveness of Single-Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS): an Updated Systematic Review" in Obes Surg 2021 "SADI-S seems to be an overall safe and effective bariatric operation." Lim also noted in UpToDate that SADI-S patients had fewer anastomotic complications, bowel obstructions, internal hernias, and volvulus, presumably because SADI-S required one fewer anastomosis than the other two procedures. 

Finally, it should be noted that the patient meets the criteria for the procedure according to MCG (Milliman Care Guidelines) Health General Recovery Care 26th Edition, Clinical Indications for Procedure Surgery. The fact that the insurer is denying the procedure because the requested procedure is not clear and that there has not been enough studies about this treatment to show that it is safe and effective is incorrect. She clearly is morbidly obese and was cleared by her medical doctor, by psychiatry and was followed by nutrition with physician supervised visits, thus she meets the criteria. This patient needs to lose weight and needs this operation so that she can improve her health.

To summarize, the denial is overturned. The procedure is likely to be as beneficial as the standard treatments/procedures for this patient. 

The carrier's denial of a surgical procedure on the stomach, procedure code 43845, should be overturned.