Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity. 
Treatment: Laparoscopic Sleeve Gastrectomy (CPT 43775) and 1 Inpatient Day, Pre-service. 

The insurer denied the  Laparoscopic Sleeve Gastrectomy (CPT 43775) and 1 Inpatient Day, Pre-service. 
The denial is upheld. 

This patient is a female under consideration for bariatric surgery. She has a body mass index (BMI) of 36 kilograms per meter squared (kg/m2). The patient has comorbid illnesses of joint pain, gastroesophageal reflux disease (GERD), and polycystic ovarian syndrome (PCOS).  She takes no prescribed medications.  The patient has a long history of prior weight loss efforts that have not been successful. These efforts are detailed in the letter of medical necessity.  While she has attempted to lose weight with conventional programs, she has been unsuccessful. 

The patient sought evaluation for evaluation for bariatric surgery. She was entered into a multidisciplinary bariatric program. She has consulted with a psychologist. The patient has been cleared for bariatric surgery from a mental health standpoint. The patient consulted with a dietician and was counseled and educated on the nutritional changes necessary with sleeve gastrectomy. Thyroid function (TSH) and glycated hemoglobin (A1c) were normal. The patient also has completed medical evaluation with cardiology consultation and pulmonary consultation.  She was cleared for the proposed surgery from a medical standpoint. 

Following this evaluation and because of persistent obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy, CPT 43775). 

The health plan rationale for denial per the letter is that there is not documentation of the presence of a life-threatening comorbidity such as hypertension, diabetes, or severe sleep apnea as required for a patient with a body mass index (BMI) between 35-40 kilograms per meter squared (kg/m2). 

No, the proposed Laparoscopic Sleeve Gastrectomy (CPT 43775) and 1 Inpatient Day are not medically necessary. 

Sleeve gastrectomy is not medically necessary based on the submitted clinical data and generally accepted standards of care in this case.  As the sleeve gastrectomy is not medically necessary, the inpatient day cannot be approved either. 

The health plan did act with sound medical judgment and in a manner consistent with the accepted standard of care.  While this patient is significantly overweight with a body mass index (BMI) of 36 kilograms per meter squared (kg/m2), she has no documented significant comorbid illness to justify performance of bariatric surgery such as Laparoscopic Sleeve Gastrectomy (LSG) at this time. 

Generally accepted guidelines for performance of bariatric surgery for a patient with class II obesity (body mass index [BMI] between 35-40 kilograms per meter squared [kg/m2]) include the presence of weight related illness that is anticipated to improve or resolve weight significant and sustained weight loss. In this case the patient is reported to have polycystic ovarian syndrome (PCOS), gastroesophageal reflux disease (GERD) and joint pain.  However, she takes no prescribed medications and there is no objective documentation to substantiate these reported conditions. 

While weight loss would be expected to be health beneficial for this patient with a body mass index (BMI) of 36 kilograms per meter squared (kg/m2), in the absence of any confirmed comorbid illness bariatric surgery is not consistent with guidelines established by the National Institutes of Health (NIH) or the American Society for Metabolic and Bariatric Surgery (ASMBS). 

As the sleeve gastrectomy is not medically necessary, the inpatient day cannot be approved either.