Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity 
Treatment: Stomach Surgery: Revision Bariatric Surgery (Conversion from Sleeve Gastrectomy to Biliopancreatic Diversion with Duodenal Switch) 

The insurer denied the Stomach Surgery: Revision Bariatric Surgery (Conversion from Sleeve Gastrectomy to Biliopancreatic Diversion with Duodenal Switch). The determination is overturned. 

This patient is under consideration for revisional bariatric surgery. He underwent a gastric band procedure in 2008. This procedure was ultimately complicated by symptoms of choking and weight recidivism and the band was removed. The patient underwent a conversion to Laparoscopic Sleeve Gastrectomy (LSG) at this time. His pre-sleeve gastrectomy weight was 315 pounds (lbs). The post-operative nadir was 235 lbs.
The patient consulted for the condition of weight gain in mid 2019. At this time, he was 70 inches tall and weighed 310 lbs. This corresponds to a body mass index (BMI) of 44 kilograms per square meter (kg/m2). The patient has obesity-related comorbid diseases of GERD. The patient has consulted and followed with his doctor for this condition. He is reported to not have significant restriction related to the sleeve gastrectomy. The submitted documentation includes progress notes that describe ongoing diet and exercise efforts. The patient has also worked with a registered dietician. A mental health evaluation was performed with clearance for the proposed revisional operation. The records include documentation of participation in a weight loss program. His weight remained in the 300 lb range during this period of time. An upper endoscopy showed severe esophagitis and anatomic changes of sleeve gastrectomy. Lab data confirms normal thyroid function. 

At issue is the medical necessity of the requested procedure, Stomach Surgery: Revision Bariatric Surgery (Conversion from Sleeve Gastrectomy to Biliopancreatic Diversion with Duodenal Switch). 

Given this patient's diagnosis, his current health condition and medical standards in the field of bariatric and metabolic surgery, the proposed revision of sleeve gastrectomy to biliopancreatic diversion with duodenal switch (BPD-DS) is medically necessary for this patient. His health conditions that include gastroesophageal reflux disease (GERD) with severe esophagitis. He has successfully completed a multidisciplinary bariatric evaluation. He has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. Finally, he has participated with a supervised weight loss program over a period of 6-months as detailed above. He has refractory medically complicated morbid obesity. 

Revisional surgery as is proposed in this case is a reasonable clinical consideration for this patient. This patient underwent sleeve gastrectomy. While he initially lost 80 lbs following surgery, he remained overweight as is sometimes experienced with restrictive bariatric operations. He has also developed severe esophagitis with esophageal ulceration that is confirmed by endoscopy. He has actively participated in a post-surgical program and he has completed the prerequisite evaluation with mental health and nutritional consultations. 

Per the American Society for Metabolic and Bariatric Surgery (ASMBS) Guidelines, the paradigm of revisional, adjuvant or escalation of therapy is well established in many medical and surgical specialties. Sleeve gastrectomy (SG) may be used as the first step in a staged operative approach for bariatric surgical patients. Conversion to either gastric bypass or BPD/DS may be performed subsequently if necessary. For high-risk or high BMI patients, utilizing the SG as the first stage of a planned staged approach is an established strategy.[5-9] In this patient group, the sleeve provides initial weight loss and co-morbidity reduction with improvement in functional status before the second-stage operation (Roux-en-Y (RYGB) or BPD/DS) that provides continued weight loss and co-morbidity reduction. Occasionally, very high BMI patients are able to achieve satisfactory weight loss with the first stage only, but the option to proceed with the second-stage bypass procedure is available based on the patient's weight, co- morbidities, and risk. The reported outcomes after reoperative bariatric surgery are generally favorable and demonstrate that additional weight loss and co-morbidity reduction is achieved with additional therapy. 

An additional indication for the proposed revisional operation is this patient's severe esophagitis. Standard surgical treatment of GERD for a non-bariatric surgical patient consists of crural re-approximation and fundoplication. However, this treatment is not an option given the specific surgical history. Conversion of the sleeve gastrectomy to duodenal switch is a standard and accepted therapy for a patient with intractable GERD/esophagitis post sleeve gastrectomy. The medical necessity of this treatment is further supported by the pathology noted on EGD. This treatment is consistent with published literature for the condition of refractory GERD post sleeve gastrectomy as is documented to exist in this case. Conversion to duodenal switch is recognized as effective treatment of refractory GERD post sleeve gastrectomy within the bariatric surgical community based on outcomes data. The proposed operation will effectively divert gastric acid away from the gastroesophageal junction and will resolve the esophagitis. 

This treatment offers this patient the only effective treatment for their refractory morbid obesity and esophagitis. There is no effective alternative therapeutic option for this patient due to their existing gastric anatomy. Prescription antacid medications are ineffective, surgical fundoplication is not an option since the fundus of the stomach has been surgically removed and magnetic sphincter augmentation has not yet been widely studied in this patient population. Conversion to an alternative bariatric operation as proposed is the standard intervention for a patient who has undergone sleeve gastrectomy and has the complication of refractory morbid obesity and severe esophagitis. 

This intervention is the accepted standard of care among those charged with the care and treatment of patients with morbid obesity and GERD complicating sleeve gastrectomy as exists in this case. This therapy will provide effective control of gastroesophageal reflux, will prevent further progression of this disease and will provide ongoing treatment of the chronic condition of morbid obesity as was initiated with sleeve gastrectomy.