Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity

Treatment: pre-elective hospital admission and surgical procedure on the stomach

The insurer denied coverage for a pre-elective hospital admission and surgical procedure on the stomach

The denial is overturned
 

As per the medical records, this is a young adult with a history of morbid obesity, hypertension (HTN), sleep apnea, fatty liver and pre-diabetes. He presented for consultation for bariatric surgery. The patient had obvious signs of sleep apnea. His weight was centered in the upper abdomen and torso. The provider noted that he will start him on low dose Ozempic. He noted the patient has severe insulin resistance. His Body Mass Index (BMI) was 58.38. 

The patient was seen for psychological screening and was found to be a good candidate for bariatric surgery.

The patient was seen for follow up to discuss his weight loss needs. He noted that despite multiple attempts with diet and exercise he has failed to achieve long term weight loss. He was also known to have a fatty liver and HTN. He noted that his weight is not due to any organic syndrome or metabolically correctable problem. As a result, he is recommending that he undergo bariatric surgery to assist in weight loss which will improve or reverse some of the existing health conditions. 

Lim RB noted in "Bariatric procedures for the management of severe obesity: Descriptions" in UpToDate 2023 that "single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is fundamentally a variant of the BPD/DS (biliopancreatic diversion with duodenal switch) operation, in which the transected duodenum is anastomosed to a loop of distal small bowel as opposed to the Roux-en-Y configuration used in classic BPD/DS. Thus, there is only one anastomosis. The SADI-S procedure was developed in part to reduce the complexity and therefore the risks of performing a Roux-en-Y configuration with small-diameter distal bowel and a need for two anastomoses. SADI-S has been endorsed by the American Society for Metabolic and Bariatric Surgery as an appropriate primary metabolic bariatric procedure". Thus, there is significant literature to support improved health outcomes after the duodenal switch whether a single or double anastomosis and the insurer is incorrect to state that it is experimental.

In terms of adverse risk which is the other part of the equation to whether or not the procedure should be considered experimental, it should be noted that the adverse risks do not appear to be increased over standard treatment services. In fact, Spinos noted in "The Effectiveness of Single-Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS): an Updated Systematic Review" in Obes Surg 2021 SADI-S seems to be an overall safe and effective bariatric operation." Yashkov noted in "SADI-S 250 vs Roux-en-Y Duodenal Switch (RY-DS): Results of 5-Year Observational Study" Obes Surg 2021 that "SADI-S has many advantages over RY-DS. However, weight loss and antidiabetic effects after the third year were marginally lower after SADI-S compared to RY-DS. SADI-S is less dangerous in terms of malabsorption and looks to be a reasonable alternative to RY-DS as a metabolic operation. RY-DS could be implemented for weight regain and/or bile reflux after SADI-S.

Based on the above, the insurer's denial must be 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 a pre-elective hospital admission and surgical procedure on the stomach is substantiated.