Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight loss surgery and inpatient care
The insurer denied Weight loss surgery and inpatient care
The determination is overturned.

This is a female patient under consideration for bariatric surgery. She was 64 inches tall and weighed 205 pounds (lbs). This corresponds to a body mass index (BMI) of 35.2 kilograms per square meter (kg/m2). She has comorbid health conditions of obstructive sleep apnea, prediabetes, and steatohepatitis. The patient has attempted weight loss with conventional dieting. She has also attempted weight loss with prescribed medication (Mounjaro). She has not been successful with significant sustained weight loss. The patient has consulted with a registered dietician. She has received nutritional counseling and education and has attempted weight loss with the prescription medication. The records indicate that she was entered into a multidisciplinary bariatric program.
The Health Plan guidelines regarding surgical treatment of morbid obesity include members that are 18 years or older, have a body mass index (BMI) greater than (&gt;) 40 or 35 kg/m2-40 kg/m2 with at least one documented comorbidity. The recommended surgery is one of the listed procedures. Completed presurgical medical and mental health evaluation and clearances, past participation in a weight loss program, inadequate weight loss despite a committed attempt at conservative medical therapy are needed. Pre-operative education, a treatment plan that addresses the pre and post-operative needs of an individual undergoing bariatric surgery are needed.
At issue is the medical necessity of weight loss surgery and inpatient care.

The requested sleeve gastrectomy and related inpatient admission is medically necessary for this patient.
Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed laparoscopic sleeve gastrectomy procedure and inpatient admission is medically necessary for this patient.
This patient has a BMI in excess of 35 kg/m2 with weight related comorbid health conditions that include obstructive sleep apnea, prediabetes, and hyperlipidemia. These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical, pulmonary and cardiology clearance.
From the available data it can be expected that laparoscopic sleeve gastrectomy and inpatient admission would be health beneficial for her and that she meets generally accepted 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery criteria for the proposed bariatric operation. [1]. These most recent published guidelines for bariatric surgical patient selection support that bariatric surgery is proven effective therapy for appropriately selected patients with BMI of at least 35 kg/m2 with or without comorbid illness (as in this case) or a BMI of at least 30 kg/m2 with weight related illness.
Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy. This patient's condition warrants treatment as is proposed and this treatment would be expected to be health beneficial for her and is consistent with internationally accepted guidelines of care.[1]
Inpatient admission is the standard of care associated with bariatric surgical interventions such as laparoscopic sleeve gastrectomy. This operation is a major surgical intervention that carries perioperative risk and requires appropriate post-surgical care and treatment. The intensity of service associated with bariatric surgical patients justifies an inpatient level of care. Sleeve gastrectomy involves the resection of 85 percent (%) of the stomach and Roux en Y gastric bypass involves division and establishment of two enteric anastomoses. These post-surgical patients are kept nothing by mouth for a period of time in the early post-surgical period, they require intravenous (IV) fluid, antiemetics, and frequent follow up regarding their surgical status and comorbid illnesses. A 1-2 day inpatient length of stay is consistent with current standards of care. A lower level of care could jeopardize this patient's health outcome. This patient's condition of medically complicated morbid obesity is consistent with generally accepted society guidelines for performance of sleeve gastrectomy and the associated inpatient stay.