Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Inpatient Surgery (43860 x 1, 43659 x 1); repeat bariatric surgery
The insurer denied coverage for inpatient surgery; repeat bariatric surgery.
The denial is overturned.

The patient has a history of the following: obstructive sleep apnea, hypertension, osteoarthritis of knee, and elevated hemoglobin A1C (glycated hemoglobin test). He is with morbid obesity and had prior laparoscopic (lap) band surgery with removal due to band malfunction (band intolerance). The patient's body mass index (BMI) is 51. The patient has been cleared by Psychology and Cardiology for bariatric surgery. He is taking a proton pump inhibitor (PPI). A request for mini gastric bypass has been made. The request was previously denied due to being considered experimental.

According to a systematic review and meta analysis, the following applies: Mini gastric bypass seems to be a simpler procedure with a better weight reduction effect. This seems to also be the case regarding remission rates of type 2 diabetes mellitus when using mini gastric bypass in comparison to Roux-en-Y gastric bypass (RYGB). 

Another review shows the following: OAGB/MGB [One Anastomosis/Mini Gastric Bypass] appears to be feasible and effective as a revision procedure after failed restrictive bariatric procedures. Another review states the following: There is enough evidence to include OAGB/MGB as an accepted standard bariatric and metabolic surgical procedure. (Kermansaravi, M., et al, 2021)

Finally, the following applies: Our meta-analysis has shown OAGB-MGB, used as revision intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique. Therefore, based on a consensus of systematic reviews, the procedure is safe and effective and would support an improvement in health outcome. (Velotti, N., et al, 2021)   

The patient has been cleared by psychology and cardiology, as well as the treating provider.     

This patient is a good candidate repeat bariatric surgery. This patient has an appropriate BMI, and preoperative workup. There were complications with the Laparoscopic adjustable gastric banding (LAGB). The patient has also failed medical therapy for gastroesophageal reflux disease (GERD). Therefore, revision bariatric surgery is indicated.     

According to the peer reviewed literature, the OAGB may be more effective and have less risk of complications than the standard RYGB.     

This patient has a BMI of 51 and has completed preoperative workup. There were complications with the LAGB and failed medical therapy for GERD. Therefore, revision bariatric surgery is indicated. The peer reviewed literature suggests the following: OAGB bypass seems to be a simpler procedure with a better weight reduction effect. This seems to also be the case regarding remission rates of type 2 diabetes mellitus when using Mini gastric bypass in comparison to RYGB. (Wang, et al, 2018) Literature suggests this should now be considered a standard procedure.  

The requested service is more likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of inpatient surgery (43860 x 1, 43659 x 1); repeat bariatric surgery should be overturned.