Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	Obesity	

Treatment: Surgical intervention

The insurer denied surgery and post operative admission

The denial is overturned

According to the documentation provided on 9/26/23 this is a patient who was being evaluated for bariatric surgery. As per the progress note, the patient has a past medical history (PMHX) of type 2 diabetes, body mass index (BMI) > 40 and mitral valve prolapse. The patient currently takes Metformin. She is status post (s/p) oophorectomy, open reduction internal fixation (ORIF) ankle, and partial hysterectomy and was undergoing medical evaluation for upcoming bariatric surgery. She has been going through the necessary medical evaluations and participating in efforts to lose weight non surgically. She has been following up monthly and has completed her medical workup. The patient wants a gastric bypass. The surgeon explained to the patient the surgery and the possibility that bypass may not be achievable given the amount of scar tissue from previous surgery.

The insurer has denied coverage for weight loss surgery (procedure code 43644) and following inpatient stay, as not medically necessary. In their Final Adverse Determination letter dated 11/16/23, that noted that they are not changing their decision to deny the surgical procedure. 
	
Based upon the evidence provided the reviewer has to disagree with the insurer as this patient does meet criteria for bariatric surgery given her BMI greater than 40. According  to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (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: Adult patient has BMI of 35 or greater (32.5 or greater in Asian patients); Adult patient has BMI of 30 to 34.9 (27.5 to 32.4 in Asian patients) and ALL of the following: Clinically serious condition related to obesity (e.g., type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe lower extremity osteoarthritis, treatment-resistant hypertension); Failure of nonsurgical therapy, as indicated by 1 or more of the following: Inadequately controlled hyperglycemia despite optimal diabetic treatment, Positive airway pressure therapy not effective or not tolerated for obstructive sleep apnea or obesity hypoventilation, Treatment-resistant hypertension, Other serious obesity-related condition insufficiently responsive to nonsurgical treatment (e.g., nonalcoholic fatty liver disease, pseudotumor cerebri, polycystic ovary syndrome, severe osteoarthritis); Adolescent patient (13 to 17 years of age) has BMI of 40 (or 140% of 95th percentile in age and sex-matched growth chart) or greater; Adolescent patient (13 to 17 years of age) has BMI of 35 (or 120% of 95th percentile in age and sex-matched growth chart) or greater and clinically serious condition related to obesity (e.g., type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, pseudotumor cerebri, Blount disease (tibia vara), slipped capital femoral epiphysis).  Patient is candidate for bariatric surgery as indicated by ALL of the following: Patient has tried and has failed to achieve and maintain significant weight loss with nonsurgical treatment,  Correctable cause for obesity not identified (e.g., hypothyroidism, Cushing syndrome), Current substance abuse not identified; Not currently pregnant and no planned pregnancy within 18 months of surgery; Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed and willing able to participate and adhere to postoperative requirements); No current untreated eating disorder; No serious untreated or uncontrolled medical, psychiatric, psychosocial or cognitive condition that would interfere with adherence to postoperative instructions, and self-care;  Patient is receiving treatment in multidisciplinary program experienced in metabolic surgery that can provide ALL of the following:  Preoperative medical consultation,  Preoperative medical health consultation, Nutritional counseling, Exercise counseling,  Patient support programs. 

Thus, this patient would meet the current guidelines as her BMI is greater than 35 and has undergone a multidisciplinary program. She does have cardiology, pulmonary and psych (social worker) clearance and has tried to lose weight as well as participating in a program as per the provider. Thus, the insurer is wrong for stating that the patient did not meet the criteria.
	
Furthermore, Eisenberg et al., noted in "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 that  Major updates to 1991 National Institutes of Health guidelines for bariatric surgery include that Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >=35 kg/m2 [kilogram per square meter], regardless of presence, absence, or severity of co-morbidities. The authors noted that "Given the presence of high-quality scientific data on safety, efficacy, and cost-effectiveness of MBS in improving survival and quality of life in patients with BMI >=35 kg/m2, MBS should be strongly recommended in these patients regardless of presence or absence of evident obesity-related co-morbidities. Current nonsurgical treatment options for patients with BMI >=35 kg/m2 are ineffective in achieving a substantial and sustained weight reduction necessary to significantly improve their general health. Physical problems related to excess body weight, undiagnosed obesity-related co-morbidities, risk of developing obesity-related co-morbidities in the future, and impaired quality of life related to physical and mental consequences of obesity threaten the general health of individuals with moderate to severe obesity even in the absence of diagnosed obesity-related co-morbidities. Thus, MBS is recommended in this population." 

Thus, given the criteria bariatric surgery in the form of gastric bypass is recommended and should be approved for this patient. This patient has a BMI of over 35 - in fact, it is over 40 and has met the criteria for bariatric surgery.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for weight loss surgery (procedure code 43644) and following inpatient stay services is substantiated.