Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight Loss Surgery (43775 x 1)
The insurer denied the weight loss surgery (43775 x 1).
The denial is overturned.

This patient is an adult female under consideration for bariatric surgery. This past summer she was 65 inches tall and weighed 222 pounds. This corresponds to a body mass index (BMI) of 37. She has comorbid health conditions of dyslipidemia for which she is treated with statin medication. The patient has attempted weight loss with dietary efforts as detailed in the evaluation. She has not been successful with significant sustained weight loss.

The patient sought evaluation for bariatric surgical consultation. The records indicate that she was entered into a multidisciplinary bariatric program. She participated in a supervised weight loss program for three months. Psychological evaluation provides mental health clearance. She has consulted with a dietician and has received nutritional counseling and education. The patient has been granted medical clearance. TSH (thyroid stimulating hormone) is normal. Following this evaluation and because of persistent morbid obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).

The health plan rationale for denial per the letter is that there is not documentation that the patient has a BMI greater than 40 or 35 with qualifying comorbid conditions, or a BMI greater than 30 with uncontrollable diabetes despite optimal medical therapy.

The requested weight loss surgery (43775 x 1) is medically necessary.

Given this patient's diagnosis, her current health condition, the plan guidelines and generally accepted guidelines for bariatric patient selection, the proposed sleeve gastrectomy procedure is medically necessary for this patient. This patient is an adult. She has a current BMI in excess of 35 with weight related comorbid health conditions that include hyperlipidemia for which is treated with prescription medication. She 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 patient's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment and is not for the convenience of the patient or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care. The health plan mandate for only certain comorbid health conditions is not consistent with nationally recognized criteria for patient selection.

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:
1) The patient meets the widely accepted NIH (National Institutes of Health) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG procedure (BMI of greater than 35, comorbid conditions of hyperlipidemia, failed nonsurgical efforts to promote weight loss). She has been granted medical and mental health clearance. 2) 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. 3) The LSG procedure is not investigational or experimental. It has garnered the support of ASMBS guidelines and has proven efficacy and greater than 5-year weight loss comparable to other bariatric procedures.

Therefore, given the above, the requested surgery is medically necessary.