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

Physician 1:  This patient is a 58-year-old female with a BMI of over 45 and comorbidities including type 2 diabetes and nonalcoholic steatohepatitis. She has completed an evaluation for bariatric surgery and her candidacy has been approved. In addition to her steatohepatitis, the patient also has evidence of splenomegaly and possible cirrhosis; there is no active ascities at this time. Sleeve gastrectomy has been recommended for surgical weight loss as gastric bypass and Lap Band were rejected because of her underlying liver disease. The patient wishes to undergo laparoscopic sleeve gastrectomy for treatment of her morbid obesity. The Health Plan denied authorization and coverage for this procedure on the basis that it has not been shown to be efficacious in the treatment of patients such as this one.There is no question the patient is appropriate for bariatric surgery based upon her BMI and her co-morbid conditions. In addition, her liver disease includes findings of early cirrhosis with possible portal  hypertension. A Lap Band would be contraindicated due to her splenomegaly and a malabsorptive procedure could negatively impact the patients liver status from a biochemical perspective. Laparoscopic sleeve gastrectomy is a clinically appropriate bariatric procedure and offers a wider margin of safety for this patient.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 58-year-old female with a body mass index of 45 and multiple co-morbid conditions, most notably nonalcoholic steatohepatitis. Her current weight makes her ineligible for liver transplant, should that become necessary in the future. The patient is under the care of a surgeon knowledgeable in both bariatric and transplant surgery, and he indicates the (vertical) sleeve gastrectomy is the only surgical weight loss procedure that can be safely performed. The Health Plan denied the patients request for authorization of the laparoscopic (vertical) sleeve gastrectomy citing the investigational nature of the procedure.The (vertical) sleeve gastrectomy is one portion of the duodenal switch operation which has been associated with improvement of liver function and the microscopic anatomy of the liver in the morbidly obese patient. This patients surgeon has enumerated several reasons why the patient is not a candidate for the Roux-en-Y or Lap Band procedures and has explained in detail why the (vertical) sleeve gastrectomy is the best and safest option for her. I concur with his analysis and  have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  This patient is a 58-year-old female who has a BMI of 45 along with end stage liver disease secondary to nonalcoholic steatohepatitis (NASH) without evidence of portal hypertension. Additional co-morbid conditions include hyperlipidemia and type 2 diabetes. The patient is not a candidate for the Roux-en-Y gastric bypass (RYGB) procedure or the Lap Band due to her liver disease. Her surgeon recommends a (vertical) sleeve gastrectomy as an isolated bariatric surgical procedure and has submitted a request for authorization. The Health Plan denied the request based upon the investigational nature of the procedure.Vertical sleeve gastrectomy is not generally performed as an isolated bariatric procedure in patients with a BMI of less then 50. However, there are compelling reasons to do so in this patients case. First of all, adequate weight loss will stabilize the patients liver disease and will make transplant possible should it become necessary. Secondly, the RYGB procedure utilizes a loop of bowel normally reserved for living relative donor transplant. Finally, dissection in the region in the gastroesophageal junction (Lap Band) could lead to significant bleeding if a dilated vessel was encountered. Overall, laparoscopic (vertical) sleeve gastrectomy is the most appropriate bariatric procedure for this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.