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

Physician 1: This patient is a 47-year-old woman with a body mass index (BMI) of 41 with comorbidities. Her provider has recommended a laparoscopic lateral sleeve gastrectomy (LSG), cholecystectomy, and liver biopsy. The Health Plan has denied authorization for the proposed surgery on the basis that LSG is considered an investigational weight loss procedure.LSG is a component of pancreatilobiliary bypass with duodenal switch. In select cases of the super obese (patients with a BMI over 60), LSG has been used as a staged procedure to induce enough weight loss and reduction in hepatomegaly that a secondary completion procedure, either Roux-en-Y or duodenal switch, can be accomplished safely. There is no evidence that a staged procedure is the preferred method of weight control in this patient; therefore, LSG is not medically appropriate. Furthermore, there is no medical indication for a cholecystectomy and liver biopsy. However, based on the patients BMI and comorbidities, she is an appropriate candidate for a conventional Roux-en-Y procedure. Based upon the information set forth above, I have determined that the requested surgery 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 47-year-old woman who has clinical obesity. Most recently, she had a body mass index (BMI) of 41. She has consulted a provider who has recommended a laparoscopic lateral gastrectomy, cholecystectomy and liver biopsy.  The Health Plan has denied authorization and coverage for the requested surgery indicating it is considered investigational.Lateral gastrectomy is a gastric restrictive procedure. Review of the relevant scientific evidence reveals that gastric restrictive procedures are less effective than gastrointestinal bypass procedures, such as Roux-en-Y. Thus, lateral gastrectomy is not likely to result in a superior outcome over standard weight loss surgery. The patient is an appropriate candidate for the Roux-en-Y procedure, which should be authorized if requested. There is no clinical need for a cholecystectomy or liver biopsy in this case.Based upon the information set forth above, I have determined that the requested surgery 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 47-year-old female with long-standing obesity with a body mass index (BMI) of 41. She has several comorbidities related to her obesity. The patient has failed medical management. She has had a psychological evaluation and is an appropriate candidate for weight loss surgery. The patients provider has proposed surgical treatment involving a laparoscopic lateral gastrectomy, cholecystectomy and liver biopsy. The Health Plan has denied the patients request for coverage for the surgery on the basis that lateral gastrectomy is investigational in nature.With a BMI of 41 and several comorbid conditions, the patient is an appropriate candidate for weight loss surgery. However, laparoscopic lateral gastrectomy is a gastric restrictive procedure, which has had a high failure rate due to continued overeating causing the gastric remnant to disease over time. It can sometimes be used as a binding procedure if needed, but does not have a good performance record when compared to gastric restriction plus malabsorptive procedures. As such, lateral gastrectomy cannot be recommended; the patients obesity can be appropriately treated with Roux-en-Y gastric bypass. Furthermore, cholecystectomy and liver biopsy are not medically warranted.Based upon the information set forth above, I have determined that the requested surgery 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.