Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician #1:  The patient is a 27-year-old male with a BMI of 68.6. His comorbid conditions include heart failure, hypertension, degenerative joint disease, incontinence and gastroesophageal reflux disease (GERD). The patient has tried different diets and they have been listed in the medical record. He has also passed his psychosocial evaluation and is a candidate for bariatric surgery.  After reviewing the surgical alternatives with his provider, the patient has requested authorization for laparoscopic vertical gastroplasty/gastrectomy. His request was denied by the Health Plan due to their conclusion that the procedure is experimental.In light of the patients high-risk clinical status and his super morbid obesity, the possibility of multiple surgeries does not seem to be the best and safest approach. It appears there are other surgical options that offer a better result than the laparoscopic vertical gastroplasty/gastrectomy.  His provider also discussed the duodenal switch procedure, which has been shown to be very effective for surgical weight loss.   Having reviewed the consultation report, it is apparent that this procedure may only downstage his risk by 200 pounds, and additional surgery may be required to achieve his weight loss goal.  Although his surgeon is knowledgeable in this technique, there is a greater body of knowledge relative to the more standard bariatric surgeries.Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #2:  The patient is a 27-year-old super obese male who is a qualified candidate for bariatric surgery. He has researched alternatives for surgical weight loss and has submitted a request for laparoscopic vertical gastroplasty/gastrectomy to his Health Plan.  The Health Plan considers this an experimental/investigational procedure and has denied authorization.The patient has a BMI of over 68.  There are subgroups of patients for whom vertical gastroplasty/gastrectomy is the only operative choice.  The application of a staged approach using the vertical gastrectomy as the initial phase is appropriate.  If necessary, the patient can subsequently be converted to a Roux-en-Y or a duodenal switch to facilitate further weight loss.   Consequently, I have determined that for a super morbidly obese patient, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #3:  The patient is 27-year-old male who has a body mass index of 68.6. He has completed the evaluation process for surgical weight loss, and is a viable candidate.  Due to his condition, there is an increased risk of surgical mortality and therefore the patient wishes to proceed with the laparoscopic vertical gastroplasty/gastrectomy.  The Health Plan has denied his request for authorization based on a determination that the procedure is experimental/investigational for the treatment of morbid obesity.As indicated in the references provided, the laparoscopic vertical gastroplasty/ gastrectomy is considered by some to be an appropriate first stage operation for surgical weight loss. However, there is a specific concern in this particular case due to the presence of the gastroesophageal reflux disease (GERD).  This condition will most likely worsen with the significant restrictive component that is needed to promote adequate weight loss with vertical gastrectomy alone. His surgeon clearly recognized that a follow up operation may be needed for adequate weight loss.  The more commonly performed duodenal switch operation, which includes the vertical gastrectomy, offers a superior result in terms of excess body weight loss.  Based on these clinical factors, I do not believe that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.