Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity, Type 2 Diabetes mellitus, Hypertension. 

Treatment: 43775 Laparoscopy, surgical gastric restrictive procedure: longitudinal gastrectomy (sleeve gastrectomy). 

The insurer denied coverage for 43775 Laparoscopy, surgical gastric restrictive procedure: longitudinal gastrectomy (sleeve gastrectomy). 

The denial is overturned. 

This is a female patient with a history of morbid obesity, hypertension (HTN), hyperlipidemia, non-insulin dependent diabetes mellitus (DM), gastroesophageal reflux diseases (GERD) and hypothyroidism who is under the care of a physician for morbid obesity and weight loss management. The patient's height is 5 feet 6 inches and her weight is 233 pounds. Her body mass index (BMI) is 37.6. The physician recommended weight loss surgery, specifically laparoscopic (lap) sleeve gastrectomy. The patient has been 100 pounds overweight for years. She has tried numerous diets and exercise attempts. 

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does meet the criteria and indications for bariatric surgery for sleeve gastrectomy as she has a BMI of 37.6 with the associated comorbidities of type 2 diabetes and HTN. She has mild obstructive sleep apnea (OSA). Thus, based upon the guidelines of MCG she does meet criteria for bariatric surgery for BMI between 35 and 39.9. This patient has a BMI of 37.6 with the associated comorbidities as listed above of diabetes as she is currently taking metformin, as well as HTN for which she takes lisinopril and therefore does meet criteria. 

As noted by Lim in Bariatric operations for management of obesity: Indications and preoperative preparation in UpToDate 2020, indications for the surgical management of severe obesity were first outlined by the National Institutes of Health (NIH) Consensus Development Panel in 1991 and reviewed by the American Bariatric Society in 2004. Candidates for a bariatric surgical procedure include: adults with a BMI greater than or equal to 40 without comorbid illness; adults with a BMI of 35 to 39.9 with at least one serious comorbidity, including but not limited to: type 2 diabetes, OSA,  HTN, hyperlipidemia, obesity-hypoventilation syndrome (OHS), Pickwickian syndrome (combination of OSA and OHS), nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), pseudotumor cerebri, GERD, asthma, venous stasis disease, severe urinary incontinence, debilitating arthritis, impaired quality of life, disqualification from other surgeries as a result of obesity (i.e., surgeries for osteoarthritic disease, ventral hernias, or stress incontinence). Thus, this patient meets the criteria based upon type 2 DM and HTN.

To summarize, the denial is overturned and coverage should not be denied for sleeve gastrectomy in this patient given her BMI of 37.6 with significant associated comorbidities. The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient in denying this indicated procedure. The patient does meet MCG and Up-to-date criteria for sleeve gastrectomy as she does have significant comorbidities with a BMI of 37.6. Therefore, the request for sleeve gastrectomy is medically necessary given the information provided. 

Based on the above, the medical necessity for 43775 Laparoscopy, surgical gastric restrictive procedure: longitudinal gastrectomy (sleeve gastrectomy) is substantiated. The insurer's denial is overturned.