Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Laparoscopic Sleeve Gastrectomy and Inpatient admission
The insurer denied the Laparoscopic Sleeve Gastrectomy and Inpatient admission.
The denial is overturned. 

This patient is a man under consideration for bariatric surgery. He is 70 inches tall and weighs 269 lbs.  This corresponds to a body mass index (BMI) of 38.6 kg/m2. His obesity related comorbid conditions include nonalcoholic steatohepatitis confirmed by abdominal ultrasonography and hypertriglyceridemia. The patient has a long history of prior weight loss efforts that have not been successful in achieving significant and sustained weight reduction. While he has attempted to lose weight with conventional programs, he has remained with medically complicated morbid obesity.  

The patient sought evaluation for bariatric surgery.  He was entered into a multidisciplinary bariatric program. He has consulted with a psychologist and has been cleared for bariatric surgery from a mental health standpoint. The patient consulted with a dietician and was counseled and educated on the nutritional changes necessary with sleeve gastrectomy.  He participated in a supervised weight loss program.  The patient has been cleared for the proposed surgery by his primary care provider. 

Following this evaluation and because of persistent medically complicated obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy) with an associated inpatient level of care.

The health plan rationale for denial was that there is not documentation a BMI (body mass index) of more than 40 kg/m2 or a BMI (body mass index) of at least 35 kg/m2 with a required comorbidity.  The denial letter states that the patient's comorbid health conditions do not warrant bariatric surgery in the setting of a BMI (body mass index) of between 35-39.9 kg/m2.

Sleeve gastrectomy and the associated inpatient admission are medically necessary based on the submitted clinical data and generally accepted standards of care.

The health plan did not act with sound medical judgment or in a manner consistent with the accepted standard of care.  Laparoscopic Sleeve Gastrectomy (LSG) will be more beneficial than any alternative non-surgical weight loss program for the treatment of this patient's medically complicated obesity. There are numerous published reports in the peer-reviewed literature describing outcomes in patients after sleeve gastrectomy. There is > 5-year follow up data that is available to support the safety and efficacy of the sleeve gastrectomy procedure.  The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 kg/m2 and excess weight loss ranging from 33% to 83%.

Comorbidity resolution 12 to 24 months after sleeve gastrectomy has been reported in numerous studies.  These studies include 5-year data that demonstrates resolution rates of diabetes, hypertension, hyperlipidemia, and sleep apnea after sleeve gastrectomy that are comparable to results of other restrictive procedures.  

With supportive 5-year data and an affirmative position statement from The ASMBS (American Society for Metabolic and Bariatric Surgery), individual consideration should be given to selected patients who are contemplating this surgical approach. Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician.  

The health plan rationale for denial was based on the contention that the patient must have a BMI (body mass index) of at least 40 kg/m2 or a BMI (body mass index) between 35-39.9 kg/m2 with weight related comorbidity.  The requirement that a patient have weight related comorbid illnesses of a certain arbitrary severity is not consistent with nationally recognized standards.  This patient has significant weight related illness (nonalcoholic steatohepatitis [NASH] and hypertriglyceridemia) that will respond favorably to the weight loss anticipated with sleeve gastrectomy.

The proposed sleeve gastrectomy is medically necessary and is consistent with the standard of care for the following reasons:  

(i)	  The patient meets the widely accepted NIH (National Institutes of Health) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure BMI (body mass index) of 38.6 kg/m2, weight related comorbid conditions that include NASH (Non-alcoholic steatohepatitis) and hypertriglyceridemia, failed nonsurgical efforts to promote weight loss.  
(ii)	The patient has been evaluated by a multidisciplinary bariatric program.  He has been counseled regarding the necessary post-surgical nutritional and lifestyle changes and has been granted mental health clearance.
(iii)   The LSG (Laparoscopic Sleeve Gastrectomy) procedure has garnered the support of ASMBS (American Society for Metabolic and Bariatric Surgery) guidelines and has proven efficacy and weight loss comparable to other bariatric procedures.

This patient is an appropriate candidate for LSG (Laparoscopic Sleeve Gastrectomy). He has been evaluated by a multidisciplinary bariatric program with nutritional and psychological consultations and he satisfies ASMBS (American Society for Metabolic and Bariatric Surgery) and NIH (National Institutes of Health) weight/BMI criteria for consideration for bariatric surgery including LSG (Laparoscopic Sleeve Gastrectomy).  LSG (Laparoscopic Sleeve Gastrectomy) is medically necessary for this patient and this procedure is likely to be health beneficial.
An Inpatient level of care is consistent with the standard of care regarding performance of sleeve gastrectomy.  This period of inpatient stay allows for provision of IV fluid, analgesia, antiemetics, and appropriate monitoring during the period of diet advancement following gastric resection.  The intensity of service associated with the management of the bariatric surgical patient warrants an inpatient designation and is consistent with the standard of medical / surgical care.