Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Morbid obesity.
Treatment:  Laparoscopic/robotic vertical sleeve gastrectomy for weight loss.

The insurer denied coverage for laparoscopic/robotic vertical sleeve gastrectomy for weight loss.  The denial is overturned.
 
As per the medical records, this is an adult patient with a history of morbid obesity. She had a lap band placed years ago and had it removed because of band slippage and dysphagia with esophagitis. As per the progress note, the patient has a history of a lap (laparoscopic) band placed and now with complication of band slippage, gastric esophageal reflux disease (GERD), dysphagia and esophagitis determined on endoscopy. She initially weighed 495 pounds and went down to 185 pounds and now has plateaued at 215 pounds. She has history of cerebrovascular accident (CVA) after her third child. At the time of this visit her weight was 209 pounds with a height of 5 feet 10 inches with a Body mass index (BMI) of 30. 

Progress notes from the NP (nurse practitioner) indicated the patient has struggled with morbid obesity for years and the provider supports her decision for weight loss surgery. She noted the patient saw cardiology and pulmonary and had sonogram and endoscopy done. Her BMI was 40.03. 

The patient saw cardiology. Her BMI was 39.73. She was cleared for surgery from a cardiac perspective.

The provider asked for preauthorization for lap sleeve gastrectomy. He noted the patient is 5 feet 10 inches and weighs 285, which calculate to a BMI of 40.89. She does have the co-morbid conditions of morbid obesity, sleep apnea, asthma, hypertension, muscle and joint pain, depression. The patient has tried multiple diets including weight watchers, Atkins, self-dieting, and physician supervised diet. He noted that his practice utilizes a multidisciplinary approach including ongoing support group meetings pre and post op. An additional letter noted the patient's morbid obesity history and the need for bariatric surgery. He noted again that she has taken part in a multi component behavioral class including nutrition counseling, behavior modification and physical exercise counseling. She has been advised not to get pregnant in the next 2 years. She has completed the preop workup including nutrition, psych, cardiology and endoscopy, as well as 2 support groups and a 1-hour nutrition class. He attached copies of her lab work to assure that the coagulation panel was normal.  

Based upon the records provided and Milliman Care Guidelines (MCG) guidelines, the patient does meet the medical criteria and indications for bariatric surgery for sleeve gastrectomy, contrary to what the insurer is stating. The patient had the lap band removed because of slippage and the complication from this. She is now seeking repeat bariatric surgery as she is morbidly obese. She gone through a multi-disciplinary approach to be cleared for surgery. She did have psychiatric clearance and does have a normal coagulation profile as noted by the provider. There is no reason for the patient not to be approved for this surgery. 

The patient needed to have her lap band removed and now went through the process again to be cleared for bariatric surgery. She met the guidelines and should be approved and not denied. 

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 inpatient surgery admission is substantiated.