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

Physician 1: The patient is a 57-year-old female who has a BMI of 41. In addition, she has the comorbid condition of stress incontinence. She is seeking Lap-Band surgery for weight loss surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan considers Lap-Band an experimental procedure and has denied authorization.Lap-Band is the leading form of weight loss surgery worldwide. Early studies were primarily from Europe and Australia. The first American studies showed a high rate of band slippage and inferior short-term weight loss. As more experience has been gained in the United States, the complication rate has dropped to below that of Roux-en-Y gastric bypass. In addition, although nadir is at 36 months rather than 12 months, average excess weight loss now approaches that of Roux-en-Y gastric bypass. As complication rates are less than Roux-en-Y gastric bypass coupled with the improvement in excess weight loss, I have determined the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Physician 2: The patient is a 57-year-old female with a BMI of 41. She is requesting authorization for Lap-Band surgery. Her comorbidities are listed as hypothyroidism secondary to treatment of Graves disease and stress incontinence. The Health Plan agrees the patient is a candidate for weight loss surgery, but has denied authorization for the Lap-Band and recommended Roux-en-Y gastric bypass.In terms of excess weight loss, Lap-Band has been shown to be less efficacious than Roux-en-Y gastric bypass or duodenal switch. Long-term, the Lap-Band has a high incidence of redo or corrective procedures. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 57-year-old female with a BMI of 41. Her comorbid conditions include stress incontinence, degenerative joint disease, and hypothyroidism. She has made numerous attempts at conservative weight loss without success. She is also considered an appropriate candidate for weight loss surgery from a psychological perspective.The patient meets nationally accepted criteria for consideration of weight loss surgery. The Food and Drug Administration approved the proposed Lap-Band procedure in 2001. Up to 80,000 worldwide have undergone the Lap-Band procedure. The morbidity of the Lap-Band is reported as lower than the Roux-en-Y gastric bypass. The Lap-Band can be adjusted at different times after the initial procedure to provide different levels of restriction. A recent study (see citations above) following 625 patients for three years showed acceptable morbidity and positive results. Excess weight loss was seen in 49.9% of patients after the second year. Overall, it appears this procedure provides greater benefit than Roux-en-Y gastric bypass. Therefore, I have determined 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.