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

Physician 1This is a 55-year-old patient with a BMI of 62. The patient has tried multiple medical regimens for weight loss without success. There are also multiple comorbid factors, which include diabetes mellitus, degenerative disc disease, hypercholestremia, and hypertriglyceridemia. Based upon the information provided, it does not appear that the patient has undergone a formal psychiatric evaluation. The patient wishes to undergo a duodenal switch procedure.I have reviewed all of the supporting documents provided. In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. Techniques in duodenal switch have been available since the 1980s. With duodenal switch, patients lose weight in the range of 69% to 80%. Complications have been reported to be comparable to other operations. Multiple vitamin deficiencies, mineral deficiencies, bacterial overgrowth issues seem all to be comparable and less than other alternative surgeries. Hundreds of duodenal switch operations have been performed on patients in California and they appear to have a good track record of positive results. Therefore, I have determined 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 overturned.Physician 2The patient is a 55-year-old woman with a body mass index (BMI) of 62. The patient has requested authorization for the duodenal switch procedure. The Health Plan has denied the patients request indicating that the duodenal switch procedure is considered investigational.The duodenal switch procedure has a track record greater than 15 years. The anticipated complication associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch. At the 2003 American Society of Bariatric Surgeons meeting held in Boston, Massachusetts, scientific papers were presented, which indicated there is growing evidence that protein malnutrition is a much larger problem post gastric bypass than was initially suspected. This is due to patients inability to consume normal meals after the gastric bypass procedure. Furthermore, there is sufficient data to show that duodenal switch has a far more superior long-term outcome when compared to the gastric bypass. Therefore, the duodenal switch procedure is medically indicated for treatment of the patients super morbid obesity. The patient should undergo a formal psychiatric evaluation and obtain clearance prior to authorization of the procedure.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Physician 3The patient is a 55-year-old female with a body mass index (BMI) of 62 who wants to undergo gastric bypass with duodenal switch. She has a number of comorbidities including gastroesophageal reflux disease and urinary stress incontinence. The Health Plan has denied authorization and coverage for the duodenal switch procedure on the basis that it is considered investigational.The patient can be appropriately treated with a Roux-en-Y gastric bypass. Her obesity will respond to Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is considered standard of care. There are no randomized, prospective trials comparing duodenal switch with Roux-en-Y gastric bypass. Thus, there is no scientific evidence to establish that duodenal switch is a more beneficial procedure than Roux-en-Y gastric bypass. Psychiatric clearance is essential prior to any weight loss surgery. Therefore, 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.