Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Sleeve Gastrectomy

The insurer denied the sleeve gastrectomy. The denial was reversed.   

This is a morbidly obese female with a medical history of obstructive sleep apnea, pre-diabetes mellitus, back and hip pain. She consulted a bariatric surgeon regarding laparoscopic sleeve gastrectomy. It was reported that the patient was very overweight for many years. She had tried numerous diets and exercise programs with failed results. As requested the patient followed up with multiple specialists to determine whether or not she was a good candidate for bariatric surgery. The specialists included a registered dietitian, a social worker, a cardiologist, and a pulmonologist. The patient underwent a sleep study; moderate non-positional obstructive sleep apnea (OSA) was determined. 

According  to the MCG Health Inpatient and Surgical Care 24th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (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: Patient has BMI of 40 or greater or Patient has BMI of 35 or greater and clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis) or Adult patient has BMI of 30 or greater with type 2 diabetes mellitus with inadequately controlled hyperglycemia (e.g., hemoglobin A1c greater than 8% despite optimal medical treatment (e.g., oral medication, insulin); Patient is candidate for bariatric surgery as indicated by all of the following: failure to achieve and maintain significant weight loss with nonsurgical treatment; correctable cause for obesity not identified (e.g., endocrine disorder); patient has demonstrated reliable participation in preoperative weight-loss program that is multidisciplinary (e.g., low-calorie diet, supervised exercise, behavior modification); current substance abuse not identified; expectation that the patient will be able to adhere to postoperative care (e.g., judged to be committed and able to participate in postoperative requirements); patient is receiving treatment in multidisciplinary program experienced in obesity surgery that can provide all of the following:  surgeons experienced with procedure; preoperative medical consultation and approval; preoperative psychiatric consultation and approval, nutritional counseling, exercise counseling, psychological counseling, support group meetings.  
This patient had a BMI of 41.02 (greater than 40) and also had comorbid conditions associated with her obesity, such as this patient's moderate obstructive sleep apnea that met the criteria of the MCG guidelines for bariatric surgery, such as the gastric sleeve procedure. The MCG guidelines also state that "[r]andomized controlled trials and systematic reviews of randomized controlled trials have found that bariatric surgery with medical treatment, compared to medical treatment alone, resulted in greater weight loss, improved glycemic outcomes in diabetics, and in some studies improvement in other obesity-related morbidities (e.g., quality of life, sleep apnea, or hypertension)." 

Based upon the records provided and the MCG guidelines reviewed, the patient met the clinical criteria and indication for bariatric surgery, such as the sleeve gastrectomy. The procedure is thus considered medically necessary to treat this patient's medical condition.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the laparoscopic sleeve gastrectomy is reversed.  The medical necessity is substantiated.