Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity
Treatment: procedure code 43775, weight loss surgery and 1 inpatient day to be rendered
The insurer denied coverage for procedure code 43775, weight loss surgery and 1 inpatient day to be rendered
The denial is upheld.

This is an adult with a history of morbid obesity, and obstructive sleep apnea (OSA). As per the provider note, the patient presented for bariatric consultation. There were failed multiple attempts at weight loss through various conservative methods of diet and exercise without any sustained weight loss. The patient has attended an informational seminar and done research. The patient has followed supervised diets: diet pills, Weight Watchers, diet shots from her doctor. They have followed the following unsupervised diet: Herbal life. Eating habits consist of binge eating, emotional eating, high carbohydrates, snacking, grazing, sweets, volume, large portions, stress eating. The bariatric physician discussed with the patient the dietary history and counseled regarding diet, nutrition, and exercise and recommended sleeve gastrectomy.

The patient was seen by dietitian for nutrition consult. She noted the plan was for sleeve gastrectomy. She noted the patient has been overweight for years and has followed the following diets: Opti fast, Weight Watchers, Optavia, Medi fast. The following medications had been used: Fen-Phen, Phenteramine, Saxenda, Contrave. The patient was educated and instructed on the diet plan. The body mass index (BMI) was 38.67. She noted the patient is making progress toward the goal of surgical control of morbid obesity. The patient was deemed a candidate for surgery.

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: adult patient has BMI of 40  or greater, or  adolescent patient (13 to 17 years of age) has BMI of 40 (or 140% (percent) of the 95th percentile in an age and sex matched growth chart) or greater, or adult Patient has BMI of 35; Current substance abuse not identified; Not currently pregnant and no planned pregnancy within 18 months of surgery; Expectation that patient will be able to adhere to postoperative care requirements (e.g., judged to be committed and willing able to participate and adhere to postoperative requirements); No current untreated eating disorder; No serious untreated or uncontrolled medical, psychiatric, psychosocial or cognitive condition that would interfere with adherence to postoperative instructions, and self-care;  Patient is receiving treatment in multidisciplinary program experienced in metabolic surgery that can provide ALL of the following:  Surgeons experienced with procedure, Preoperative medical health consultation, Nutritional counseling, Exercise counseling,  Patient support programs. 

This patient has a BMI of approximately 38 to 39. There are no records showing multiple visits and BMI. There are no records showing the patient was seen multiple times in consultation for screening evaluation regarding weight reduction surgery. There are no records showing that the patient has co morbidities that justify having bariatric surgery with a BMI between 35 to 40. The provider states that the patient has OSA but does not supply any documentation. There was only one registered dietician visit. Given her BMI between 35 and 40 and without any co morbidities as noted by MCG, she does not meet the guidelines for bariatric surgery.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the procedure code 43775, weight loss surgery and 1 inpatient day to be rendered is upheld. Medical Necessity is not substantiated.