Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Bariatric Surgery. 
The insurer denied: Bariatric Surgery. 
The denial is overturned. 

This patient is an adult male under consideration for bariatric surgery. Six months ago, he was 70.47 inches tall and weighed 480 pounds. This corresponds to a body mass index (BMI) of 67.9. The patient has attempted weight loss with conventional weight loss programs and exercise. He has also utilized prescribed weight loss medications such as Phentermine and Topamax. Unfortunately, he has not been successful with significant sustained weight loss. The patient sought evaluation for bariatric surgical consultation 6 months ago with follow up each month for the following 2 months. The records indicate that he was entered into a multidisciplinary bariatric program. Pulmonary evaluation was performed 6 months ago at which time he was diagnosed with obstructive sleep apnea. Cardiology consultation was performed 5 months ago, and he was cleared for the proposed surgery from a cardiology perspective. The patient attended monthly appointments with his primary care doctor at 6 months, 5 months and 4 months ago. Psychological evaluation provides mental health clearance six months ago. The patient consulted with a registered dietician and received nutritional counseling and education 6 months ago, 5 months ago and 4 months ago. TSH (thyroid stimulating hormone) was normal. Following this evaluation and because of persistent medically complicated obesity, the patient was deemed a suitable candidate for bariatric surgery (laparoscopic sleeve gastrectomy). Both sleeve gastrectomy and roux en Y gastric bypass was considered and reviewed with the patient. The health plan rationale for denial of coverage is that there is not documentation of active participation with a supervised physician directed weight loss program for six months without gaps or three months in a multidisciplinary weight loss program with inability to maintain weight. The denial is being appealed. 

The requested Bariatric Surgery is medically necessary. 

Given this patient's diagnosis, his current health condition and generally accepted guidelines for patient selection, the submitted records establish that either laparoscopic sleeve gastrectomy or laparoscopic roux en Y gastric bypass would be medically necessary for this patient. This patient has a BMI (body mass index) of 67.9 with weight-related comorbid health conditions that include obstructive sleep apnea. He has successfully completed a multidisciplinary bariatric evaluation. He has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. He has been granted medical clearance with cardiology and pulmonary assessments. 
Laparoscopic sleeve gastrectomy is medically necessary for this patient per widely accepted guidelines as his BMI (body mass index) is in excess of 35. From the available data, it can be expected that LSG (Laparoscopic Sleeve Gastrectomy) would be health beneficial for him, and that he 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 with or without comorbid illness (as in this case) or a BMI (body mass index) of at least 30 with weight-related illness. The requested bariatric surgical intervention is medically necessary and is consistent with evidence-based medicine in this case.