Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight loss surgery (laparoscopic sleeve gastrectomy [43775]) and inpatient hospital admission (pre-service)
The insurer denied the Weight loss surgery (laparoscopic sleeve gastrectomy [43775]) and inpatient hospital admission (pre-service)
The denial is overturned. 

This patient is a female under consideration for bariatric surgery. She is 63 inches tall and weighs 215 pounds.  This corresponds to a body mass index (BMI) of 38.1 kilograms per meter squared (kg/m2). Her obesity related comorbid conditions include hyperlipidemia/hypertriglyceridemia, joint pain and peripheral edema. The patient has a long history of prior weight loss efforts that have not been successful. While she has attempted to lose weight with conventional programs, she has remained with medically complicated morbid obesity.  The records indicate that this patient has undergone lap band surgery developed a malpositioned lap band (slippage) confirmed by upper endoscopy.  This required that the existing band be decompressed of its fluid.  Subsequent to emptying the lap band, the patient has gained weight.  The lap band was removed.

The patient sought evaluation for bariatric surgery.  She was entered into a multidisciplinary bariatric program. She has consulted with a psychologist and has been cleared for bariatric surgery from a mental health standpoint. The patient consulted with a dietician and was counseled and educated on the nutritional changes necessary with sleeve gastrectomy.  The patient also has completed cardiology and pulmonary evaluations.  

Following this evaluation and because of persistent medically complicated obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy).

The health plan rationale for denial was that there is not documentation of a body mass index (BMI) of more than 40 kilograms per meter squared (kg/m2) or a body mass index (BMI) of at least 35 kilograms per meter squared (kg/m2) with a required comorbidity.  The denial letter states that the patient's comorbid health conditions do not warrant bariatric surgery in the setting of a body mass index (BMI) between 35-39.9 kilograms per meter squared (kg/m2).

Yes, the proposed sleeve gastrectomy and the associated inpatient admission are medically necessary based on the submitted clinical data and generally accepted standards of care.

The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.

The requested service laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient for the following reasons:  
(i)	  The patient meets the widely accepted National Institute of Health (NIH) and the American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the laparoscopic sleeve gastrectomy (LSG) procedure (body mass index ([BMI] of 38 kilograms per meter squared [kg/m2], weight related comorbid conditions that include hyperlipidemia / hypertriglyceridemia, joint pain and peripheral edema, failed nonsurgical efforts to promote weight loss.  
(ii)	The patient has been evaluated by a multidisciplinary bariatric program.  She has been counseled regarding the necessary post-surgical nutritional and lifestyle changes and she has been granted mental health clearance.
(iii)   The LSG procedure is not investigational or experimental.  It has garnered the support of American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines and has proven efficacy and weight loss comparable to other bariatric procedures.

This patient is an appropriate candidate for laparoscopic sleeve gastrectomy (LSG). She has been evaluated by a multidisciplinary bariatric program with nutritional and psychological consultations and she satisfies American Society for Metabolic and Bariatric Surgery (ASMBS) and National Institute of Health (NIH) weight / body mass index (BMI) criteria for consideration for bariatric surgery including laparoscopic sleeve gastrectomy (LSG).  Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient and this procedure is likely to be health beneficial for her.
One-day of inpatient confinement is consistent with the standard of care regarding performance of sleeve gastrectomy.  This period of inpatient stay allows for provision of intravenous (IV) fluid, analgesia, antiemetics, and appropriate monitoring during the period of diet advancement following gastric resection.  The intensity of service associated with the management of the bariatric surgical patient warrants a inpatient designation and is consistent with the standard of medical / surgical care.