Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity status-post Roux-en-Y gastric bypass (RYGB).
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld.
As per the medical records history and physical, this is an adult with a body mass index (BMI) of 54 presented today for scheduled roux-en-Y gastric bypass (RYGB). The patient has a history of gastroesophageal reflux disease (GERD) and diabetes mellitus (DM) on Metformin. The operative note indicates the patient underwent a successful RYGB. The patient did well and was discharged. Nutrition notes was included to show the patient was taught about post-operative diet following this surgery. No other records were included for review.

MCG guidelines for Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy were included for review. 

Based upon the evidence provided I have to agree with the insurer as there are no records to show the patient complied with a workup needed to be approved for roux-en-Y gastric bypass (RYGB). There are no records of medical consultation, psych clearance, nutrition consultation or a multi-disciplinary approach. According  to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC) the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure, as indicated by 1 or more of the following: Adult patient has BMI of 35 or greater (32.5 or greater in Asian patients); Adult patient has BMI of 30 to 34.9 (27.5 to 32.4 in Asian patients) and ALL of the following: Clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe lower extremity osteoarthritis, treatment-resistant hypertension); Failure of nonsurgical therapy, as indicated by 1 or more of the following: Inadequately controlled hyperglycemia despite optimal diabetic treatment, Positive airway pressure therapy not effective or not tolerated for obstructive sleep apnea or obesity hypoventilation, treatment-resistant hypertension, other serious obesity-related condition insufficiently responsive to nonsurgical treatment (e.g., nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe osteoarthritis). Patient is candidate for bariatric surgery as indicated by ALL of the following: Patient has tried and has failed to achieve and maintain significant weight loss with nonsurgical treatment, correctable cause for obesity not identified (e.g., hypothyroidism, Cushing syndrome), current substance abuse not identified; Not currently pregnant and no planned pregnancy within 18 months of surgery; Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed and willing able to participate and adhere to postoperative requirements); No current untreated eating disorder; No serious untreated or uncontrolled medical, psychiatric, psychosocial or cognitive condition that would interfere with adherence to postoperative instructions, and self-care; Patient is receiving treatment in multidisciplinary program experienced in metabolic surgery that can provide ALL of the following: Preoperative medical consultation, preoperative medical health consultation, nutritional counseling, exercise counseling, patient support programs. Thus, this patient would not meet the current guidelines even though her BMI greater than 40. However, there are no records to show the multi-disciplinary approach or any other records. Thus, the reviewer believes that surgery should not be approved in this case.
	
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.