Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight loss surgery (procedure code 43775) and related hospital admission
The insurer denied coverage for weight loss surgery (procedure code 43775) and related hospital admission.
The denial is overturned.

This is an adult patient with a history of morbid obesity, hyperlipidemia, obstructive sleep apnea (OSA), asthma, anemia, and hypertension. The patient was seen for bariatric evaluation. The body mass index (BMI) was 37.46. The surgery was explained, and the plan was for bariatric surgery.

According to Milliman Clinical Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy ORG: S-516 (ISC), the procedure is indicated by ALL of the following: adult Patient has BMI of 35 or greater and clinically serious condition related to obesity (such as type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis, difficult to control hypertension); Expectation that patient will be able to adhere to postoperative care requirements (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: Surgeons experienced with procedure, Preoperative medical health consultation, Nutritional counseling, Exercise counseling, Patient support programs. 

The patient was seen for sleep disorder. The physician noted the patient had a home sleep study which showed an apnea-hypopnea index (AHI) of 3%. The physician noted that the study showed mild OSA and recommended continuous positive airway pressure (CPAP) and oral appliance therapy (OAT). However, the patient wears braces so OAT is not an option. The sleep apnea questionnaire showed the patient to be at high risk of OSA.

The patient was also seen for dietary counseling. It was noted that the patient's BMI was 37.62. The patient was educated on sleeve gastrectomy and the patient appeared willing to comply with the postoperative diet. The patient was felt to be an appropriate candidate for bariatric surgery from a nutrition standpoint. The patient underwent bariatric psychological assessment and was found to be a suitable candidate for weight loss surgery. A small bowel capsule endoscopy was done which showed normal small bowel capsule study. An esophagogastroduodenoscopy (EGD) was done and was normal. The patient was seen for a cardiologic preoperative exam for clearance for sleeve gastrectomy and was cleared for surgery. The patient was seen for medical clearance from the primary care provider. The patient's BMI was 36.10. BMIs were documented on several other visits and were consistently above 35. The patient was cleared.

This patient has a BMI over 35 with significant comorbidities of sleep apnea and hypertension. On the sleep study the patient had a score of 5 which means the patient is at risk for severe sleep apnea. Although the home sleep study showed a lower AHI, the patient does have sleep apnea. In fact, at home sleep studies underestimate the AHI by as much as 15%. 

Based upon the records submitted, the patient does meet criteria for bariatric surgery as the patient does have significant comorbidities to justify surgery. 

Based on the above, the insurer's denial is overturned. 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 43775) and related hospital admission is substantiated.