Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: This patient is a 50-year-old female with a body mass index (BMI) of 44.3. She has had the appropriate evaluations and is considered to be a viable candidate for bariatric surgery. The patients provider offered multiple options for the weight loss surgery and the patient has chosen an isolated vertical gastrectomy as her procedure of choice. The patient now requests authorization for the selected surgical procedure. The Health Plan considers the vertical gastrectomy (gastroplasty) experimental/investigational and has denied authorization and coverage.The vertical gastrectomy is now utilized as a component of the pancreaticobiliary bypass with duodenal switch (PBB/DS). Although there is support for staged PBB/DS in the super obese (gastrectomy alone, followed by the malabsorptive component), the use of vertical gastrectomy as a definitive procedure is not considered mainstream. The three forms of bariatric surgery currently supported by American Society for Bariatric Surgery and National Institutes of Health are Roux-en-Y gastric bypass, adjustable silicone banding (Lap Band) and the PBB/DS. I agree that long-term data on the efficacy of vertical gastrectomy is lacking and I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This patient is a 50-year-old, morbidly obese female with comorbidities who meets the standard criteria for weight loss surgery. She has considered the surgical alternatives, and has requested authorization for laparoscopic restrictive vertical gastroplasty (gastrectomy). The Health Plan denied her request based on a determination that the procedure is experimental/investigation for surgical treatment of the patients morbid obesity.The literature does not support the superiority of this procedure. Simple restrictive gastric procedures have consistently been shown to fail and therefore this procedure carries with it the risk of a gastric leak. There are no benefits to this procedure that are greater than those offered by the standard bariatric surgeries. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 50-year-old female with a BMI of 44.3 and comorbid conditions.  She has documented her attempts at weight loss and has been psychologically evaluated. The patient meets the National Institutes of Health criteria for weight loss surgery. She has elected to undergo laparoscopic restrictive vertical gastroplasty (gastrectomy) and has requested authorization for the procedure.  The Health Plan has denied her request citing the experimental/investigational nature of restrictive vertical gastroplasty.Definitive laparoscopic restrictive gastrectomy has been performed and studies have been published on the results. Unlike the more commonly performed Roux-en-Y, there is no dumping syndrome, marginal ulceration or nutritional deficits (Vitamin B12 and protein).Data on this procedure at three to five years demonstrates an excess body weight loss (EBWL) of approximately 50%. This is similar to three to five year outcomes for the more traditional surgical approaches. The restrictive gastrectomy represents a less invasive option with the potential for conversion to a duodenal switch if weight loss is inadequate over the long term.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.