Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity.

Treatment: laparoscopic sleeve gastrectomy procedure

The insurer denied coverage for laparoscopic sleeve gastrectomy procedure. The denial was upheld.

This patient is a female with a history of esophageal reflux, htpertension, and asthma who is requesting bariatric surgery/laparoscopic sleeve gastrectomy to address her morbid obesity. As per one progress note the patient has been going through the necessary medical evaluations which she has completed. She has been actively participating in efforts to lose weight. Her BMI was 37.05 and her BP was 130/72. She has been compliant with her workup and participation in the weight loss program. Prior notes indicated a BMI of 37.1, 36.61, 37.20, 35.42, 35.78, and 36.49. In addition, the note on a specified date indicated the patient has several failed attempts with weight loss including Atkins, Keto, Cabbage diet, Slim Fast, South Beach and Weight Watchers.

The patient had a nutrition consult at which time her BMI was 38.38 and noted that literature was provided to the patient and the patient verbalized understanding of the requirements for bariatric surgery.The patient underwent Apnea Link study and was found to have sleep apnea with an AHI of 17.9 and RI of 21. The patient was found to have moderate sleep apnea and was recommended to have nasal continuous CPAP. Preoperative pulmonary clearance was obtained where it was noted that she has cut down on her smoking and that she has obstructive sleep apnea (OSA). He found no pulmonary contraindications to the planned procedure.

Based upon the records provided and MCG guidelines, the patient does not meet the criteria and indications for bariatric surgery for sleeve gastrectomy. At the most recent visit the patient had a BMI of 37.05 and has never had a BMI greater than 40. She does not have severe sleep apnea/ OSA but rather only moderate obstructive sleep apnea with an apnea hypopnea index of only 17/hour and not > 30. She does not have diabetes. Although she has undergone appropriate evaluation including psych, nutrition, and followed a medically supervised program, she does not meet the BMI criteria and she does not have significant co-morbidities. In addition, as noted in a prior denial letter her program is not considered a Center of excellence and therefore is not an approved program. According to MCG Health Inpatient and Surgical Care 23nd Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (ISC) the procedure is indicated by several criteria. This patient has a BMI of 37.05 and does not have significant sleep apnea as co-morbidity.  She also does not have diabetes and therefore does not meet criteria.

To summarize the denial is upheld at this time, and coverage should not be provided for bariatric surgery in this patient using sleeve gastrectomy at the present time. The healthcare plan did act reasonably and with sound medical judgment and in the best interest of the patient in denying this indicated procedure. The patient does not meet MCG criteria for bariatric surgery via sleeve gastrectomy as she does not have a BMI above 40 currently but rather a BMI of 37 and only at best moderate OSA, as a co-morbidity. Therefore, the request for bariatric surgery in the form of sleeve gastrectomy is not medically necessary given the information provided. 

Based on the above, the medical necessity for the laparoscopic sleeve gastrectomy procedure is not substantiated.  The insurer's denial is upheld.