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

Physician 1: The patient is a 45-year-old female with a body mass index (BMI) of 44. She has multiple comorbidities. She has requested authorization and coverage for laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied this request indicating that the efficacy of the requested procedure remains unproven.Restrictive vertical gastroplasty/gastrectomy is generally appropriate as a component of a staged procedure in the super obese (BMI greater than 60). As an isolated procedure, there are no large studies to confirm its long-term efficacy. The American Society of Bariatric Surgeons does not recognize restrictive vertical gastroplasty/gastrectomy as an isolated bariatric procedure. Furthermore, the requested procedure does not fall within the Health Plan guidelines of approved bariatric procedures. With a BMI of 44, the patient should benefit from standard surgical weight loss procedures. Accordingly, 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: The patient is a 45-year-old female with a body mass index (BMI) of 44. She has requested authorization for laparoscopic restrictive vertical gastroplasty/gastrectomy.  She reports multiple comorbidities including hypercholesterolemia, gastroesophageal reflux disease (GERD), chronic ankle edema, and degenerative joint disease. The Health Plan has denied the patients request indicating that the requested procedure is considered investigational for treatment of morbid obesity.Restrictive vertical gastroplasty/gastrectomy differs from vertical-banded gastroplasty (VBG). With VBG, a synthetic mesh is utilized to create a very narrow stomach pouch. It has a very high failure rate and very few surgeons currently perform the procedure. Restrictive vertical gastroplasty/gastrectomy does not utilize synthetic mesh; with this procedure, the majority of the stomach is removed from the abdominal cavity. While some patients who do not have reflux disease may benefit from the procedure, it has not been established to be superior to standard bariatric procedures in patients such as this patient. While it is nearly impossible to perform any randomized surgical trial to compare two procedures head to head for outcome, complications, and efficacy, the scientific community relies on large data sets to provide the basis for outcome and efficacy when it relates to a surgical procedure. This information is lacking in the case of laparoscopic restrictive vertical gastroplasty/gastrectomy. Therefore, 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 3: The patient is a 45-year-old female with a body mass index (BMI) of 44. She has multiple comorbidities. The patient meets accepted criteria for weight loss surgery. After considering the available surgical options, the patient has decided that she wishes to undergo laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied authorization and coverage for this procedure citing the lack of peer-reviewed scientific literature supporting its efficacy.The patient has extensively reviewed her options. A gastric restrictive procedure has been recommended. The requested procedure has been described in scientific literature not only as a staging procedure but also as a definitive procedure. The proposed procedure has an acceptable success rate and risk profile. Hence, it is a medically reasonable alternative in this case. For these reasons, 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.