Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Weight Loss Surgery and Inpatient Hospital Admission.

The insurer denied: Weight Loss Surgery and Inpatient Hospital Admission.  The denial is overturned.

This patient is an adult female under consideration for bariatric surgery. Four months ago, she was 69 inches tall and weighed 254 pounds (lbs). This corresponds to a body mass index (BMI) of 37.5 kg/m2 (kilograms/square meter). She has comorbid health conditions of hypertension and hyperlipidemia. The patient has attempted weight loss with conventional weight loss programs such as diet and exercise. 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 consulted with a registered dietician and received nutritional counseling and education. Pulmonary and cardiology consultations have been completed with medical clearance for the proposed bariatric operation. A polysomnogram confirmed the diagnosis of obstructive sleep apnea for which continuous positive airway pressure (CPAP) was offered. Upper GI (gastrointestinal) endoscopy was completed that identified no anatomic contraindications to the proposed bariatric operation. TSH (thyroid-stimulating hormone) was normal. Following this evaluation and because of persistent medically complicated obesity the patient was deemed a suitable candidate for bariatric surgery (laparoscopic roux en Y gastric bypass and an associated inpatient level of care).

The health plan rationale for denial is that the required health plan criteria are not met (BMI is less than 40 kg/m2 without qualifying obesity related comorbidity).

The proposed laparoscopic roux en Y gastric bypass and the associated inpatient stay) is medically necessary.

This patient has a BMI (body mass index) in excess of 35 kg/m2 with weight related comorbid health conditions that include sleep apnea for which CPAP (continuous positive airway pressure) is proposed, hyperlipidemia for which she is prescribed atorvastatin, and hypertension. These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic roux en Y gastric bypass. She has successfully completed a multidisciplinary bariatric evaluation. Laparoscopic roux en Y gastric bypass is medically necessary per widely accepted guidelines as her BMI (body mass index) is in excess of 30 kg/m2 in association with weight related illness of sleep apnea, hyperlipidemia, and hypertension. She meets generally accepted 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery criteria for the proposed bariatric operation. [1]. These most recent published guidelines for bariatric surgical patient selection support that bariatric surgery is proven effective therapy for appropriately selected patients with BMI of at least 35 kg/m2 with or without comorbid illness or a BMI (body mass index) of at least 30 kg/m2 with weight related illness. Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy. This patient's condition warrants treatment as is proposed and this treatment would be expected to be health beneficial for her and is consistent with internationally accepted guidelines of care [1].

Inpatient admission is the standard of care associated with bariatric surgical interventions such as roux en Y gastric bypass. This operation is a major surgical intervention that carries substantial risk and requires appropriate post-surgical care and treatment. A one-day inpatient length of stay is consistent with the referenced Milliman Care Guidelines (MCG) in this case.