Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Surgical procedure on the stomach
The insurer denied the surgical procedure on the stomach.
The determination is overturned.

This is a male patient under consideration for bariatric surgery. He was 69.5 inches tall and weighed 248.5 pounds (lbs). This corresponds to a body mass index (BMI) of 36.1 kilograms per square meter (kg/m2). He has a comorbid health condition of dyslipidemia for which he is treated with statin medication. He also has prediabetes and hypertension that is treated with prescribed medication. The patient has attempted weight loss with dietary efforts. However, he has not been successful with significant sustained weight loss.
The patient sought evaluation for bariatric surgical consultation. The records indicate that he was entered into a multidisciplinary bariatric program. He participated in a supervised weight loss program. A mental health evaluation provides clearance. He consulted with a dietician and received nutritional counseling and education. The patient was granted medical clearance per the pre-operative pulmonary evaluation and progress note. His thyroid stimulating hormone (TSH) was normal. Following the evaluation and because of persistent morbid obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).
At issue is the medical necessity of the requested surgical procedure on the stomach.
Given this patient's diagnosis, current health condition, and generally accepted guidelines for bariatric patient selection, the proposed sleeve gastrectomy procedure is medically necessary for this patient. This patient has a current BMI in excess of 35 kilograms per square meter with weight related comorbid health conditions that include hyperlipidemia and hypertension for which he is treated with prescription medication. He has successfully completed a multidisciplinary bariatric evaluation with medical and mental health clearance.
Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.
LSG (laparoscopic sleeve gastrectomy), is medically necessary for this patient based on the current standard of care and evidence-based literature for the following reasons:
(i) The patient meets the widely accepted National Institute of Health (NIH) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure (BMI of greater than (>) 35 kilograms per square meter (kg/m2), comorbid conditions of hypertension and hyperlipidemia, failed nonsurgical efforts to promote weight loss. He has been granted medical and mental health clearance.
(ii) The patient has been evaluated by a multidisciplinary bariatric program. There is documentation of consultation with a dietician, a mental health provider, a medical provider, and a bariatric surgeon.
(iii) The LSG procedure has garnered the support of the ASMBS guidelines and has proven efficacy and >5-year weight loss comparable to other bariatric procedures.