Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric Stenosis

Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is a patient with a past medical history of systemic lupus erythematosus, Sjogren syndrome, chest pain, hypothyroidism, gastroesophageal reflux disease (GERD), morbid obesity, and status post gastric sleeve years ago. She presented to the Emergency Department (ED) with severe, worsening nausea and abdominal pain. On exam, she had tenderness to palpation and distention in the abdomen. The patient underwent a diagnostic laparoscopy where stenosis and stricture at the incisura was found. Laparoscopic gastrectomy with Roux en y gastric bypass (RYGB), adhesiolysis, hiatal hernia repair, esophagogastroscopy and omentopexy were completed. Postoperatively, the patient received intravenous (IV) famotidine and pain medications. Once the patient was clinically stabilized, achieving a gradual improvement in her acute presenting symptoms, demonstrating adequate pain control with no evidence of acute post op complications, the patient was discharged home. 

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does meet the criteria and indications for inpatient stay for this revision of bariatric surgery. The patient had complications related to her sleeve gastrectomy with stenosis and stricture at the incisura leading to gastric distension associated with nausea and vomiting, requiring revision to a Roux en y gastric bypass.

According to MCG Health Inpatient and Surgical Care 25th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy (1), the operative status criteria is inpatient. Furthermore, there are references that note sleeve gastrectomy can require revision because of complications. 

Yorke, et al (3) did a retrospective review of patients who underwent conversion from sleeve gastrectomies (SGs) to Roux en y gastric bypasses (RYGBs). They found 6.6% (percent) were converted from SGs to RYGBs, most commonly due to inadequate weight loss and severe reflux. They concluded that revision to RYGB is a safe option for SG failure and resulted in significant benefits from co-morbidity resolution.

Finally, Agnihotri, et al (4) reported that gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. They found that endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. However, Patients with severe stenosis or helical stenosis are likely to require revision RYGB. 

Thus, in this case where the provider noted the stenosis of the incisura, the decision was made to do revision with a RYGB bypass with adhesiolysis and repair of hiatal hernia. All of these must be done as an inpatient status and not an observation status, as noted by MCG. The patient does meet MCG criteria for inpatient status for this surgery which included diagnostic laparoscopy, hiatal hernia repair, and gastric reconstruction with RYGB. 

Based upon the above, the health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
	
The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.