Appeal type: Medical necessity
Decision: Overturned

Diagnosis:   Morbid obesity.
Treatment:  Bariatric Surgery (CPT 43644).

The insurer denied the Bariatric Surgery (CPT 43644).  The denial is overturned. 

The patient is a woman, who is morbidly obese.  She sought evaluation for the condition of refractory morbid obesity.  The records also indicate that the patient underwent gastric sleeve surgery several years prior.  Her post-surgical weight nadir following that operation was 240 pounds.  She sought evaluation for the condition of weight gain.  Her weight at this time was 276 pounds.  Her height is 68 inches, and her body mass index (BMI) is 42 kg (kilograms)/m2 (meters squared).  

The records do not include post-surgical progress notes following the initial operation.  Nutritional notes describe diet, physical activity and behavioral modification counseling.  She has also had a psychological evaluation and has been cleared for the proposed operation from a mental health standpoint letter of clearance.  Thyroid function is normal.  The surgical consultation states that a contrast upper gastrointestinal series (UGI) and upper endoscopy were to be performed to evaluate the sleeve gastrectomy.   These study reports are not included with the original review material.

Following completion of an evaluation and due to refractory morbid obesity, the provider offered conversion of the sleeve gastrectomy to laparoscopic Roux-en-Y gastrojejunostomy.  This treatment is proposed as a bariatric tool to promote additional weight loss and improve health with improvement or resolution of comorbid illnesses.

The health plan denial letter states that revision or conversion to another medically appropriate procedure because of unsatisfactory weight loss, due to technical failure of the primary bariatric procedure, such as pouch dilatation, or an initial pouch size that is too large, is considered medically appropriate if there is documentation regarding:
Primary procedure was initially successful in inducing weight loss, AND the patient has remained compliant for at least six months to a prescribed nutrition and exercise program.

Additional notes include a progress note from the provider.  This note documents the patient's body mass index (BMI) at 42 kilograms per meter squared (kg/m2), and the rationale for the proposed weight loss operation (Roux-en-Y gastric bypass) was to achieve additional weight loss.  The records also include post-operative instructions and informational hand-outs.  There is an appeal letter from the provider.  The records also include an upper endoscopy study that describes a small hiatal hernia, an irregular Z-line and a normal appearing stomach.  The esophagogastroduodenoscopy (EGD) report states that the stomach did not appear as if sleeve gastrectomy had been performed except for a slightly smaller fundus.

Yes, the proposed treatment is medically necessary.  The submitted documentation does support the medical necessity of revisional bariatric surgery for this patient at this time.

The surgical consultation states that a contrast upper gastrointestinal (UGI) study and upper endoscopy were to be performed to evaluate the sleeve gastrectomy.  Additional notes include a progress note from the provider.  This note documents the patient's body mass index (BMI) at 42 kilograms per meter squared (kg/m2).  The records also include an upper endoscopy study that describes a small hiatal hernia, an irregular Z-line and a normal appearing stomach.  The esophagogastroduodenoscopy (EGD) report states that the stomach did not appear as if sleeve gastrectomy had been performed except for a slightly smaller fundus.

This patient underwent sleeve gastrectomy several years ago.  She reached a weight nadir of 240 pounds, but gradually gained weight.  The records do not include any assessment of the gastric anatomy post sleeve gastrectomy.  The esophagogastroduodenoscopy (EGD) report does support the conclusion that there is a post-surgical complication of the initial procedure that contributes to weight gain.  The stomach is of essentially normal size and volume per the esophagogastroduodenoscopy (EGD) report.

This patient does have a body mass index (BMI) in excess of 40 kilograms per meter squared (kg/m2), has participated with a supervised diet program, does not have an endocrinopathy that is contributing to weight gain, and has been granted mental health clearance.  There is also a newly submitted anatomic evaluation of the existing gastric sleeve that documents an enlarged gastric sleeve and supports the conclusion that this contributes to weight gain.  Based on the additional clinical material, the medical necessity of the proposed revisional bariatric operation is established.  Laparoscopic Roux-en-Y gastric bypass will reduce the gastric reservoir size and will provide malabsorption that will help this patient achieve weight loss with improvement or resolution of weight-related comorbid health conditions.