Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Revision of gastrojejunal anastomosis 
(gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection (43860)
The insurer denied: Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection (43860)
The denial is upheld.

This patient is an adult female under consideration for revisional bariatric surgery. She underwent the sleeve gastrectomy procedure. The submitted records do not state when this operation was performed, her weight prior to sleeve gastrectomy, or how much weight she was able to lose and maintain after this initial bariatric intervention. The patient consulted with her surgeon for consideration of revisional bariatric surgery for the 
stated condition of post-sleeve gastrectomy gastroesophageal reflux disease (GERD). A note dated 4 months ago documents her height at 62.5 inches and her weight at 202 pounds (body mass index 36.4). At this time, her only prescribed medication was medroxyprogesterone. The records include telehealth visits that state that the patient has moderate/severe reflux and a hiatal hernia. She has been treated for her symptoms with Tums, and she was prescribed omeprazole 4 months ago. These notes state that the patient has persistent reflux symptoms despite PPI (proton pump inhibitor) therapy. The patient was evaluated with upper endoscopy 4 months ago that showed anatomic changes of sleeve gastrectomy with distal grade A esophagitis and a 2-centimeter hiatal hernia. The Z-line was normal in appearance. There was reported to be retained fundus of the stomach without 
stricture of the sleeve stomach. A stomach antral biopsy was obtained that showed normal antral mucosa. The records include a nutrition visit from 4 months ago. The patient's surgeon has proposed conversion of the sleeve gastrectomy to roux en Y gastric bypass and hiatal hernia as a means to treat refractory GERD (gastroesophageal reflux disease) post sleeve gastrectomy. The health plan rationale for denial is that the patient has had weight loss surgery and is asking for revisional weight loss surgery. Per this letter, the health plan policy 
states that conversion of sleeve gastrectomy to roux en Y gastric bypass for the treatment of GERD (gastroesophageal reflux disease) is medically necessary when anti-reflux medical therapy has been tried and failed. The denial is being appealed.

The revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection (43860) is not medically necessary.

Based on the submitted records and standards within the field of bariatric surgery, the requested revisional surgery is not medically necessary at this time, as there is no confirmation of refractory, post-sleeve GERD (gastroesophageal reflux disease) or hiatal hernia. Therefore, the requested intervention is not in accordance with generally accepted standards of medical practice and is not clinically appropriate or known to be effective for the condition being treated. The submitted records do not state when the initial operation was performed, her weight prior to sleeve gastrectomy, or how much weight she was able to lose and maintain after this initial bariatric intervention. She was started on PPI (proton pump inhibitor) therapy 4 months ago. The submitted records include only an upper endoscopy that was performed by the treating surgeon. However, there is no confirmatory esophageal biopsy, pH study while off acid suppression therapy, or contrast UGI (upper gastrointestinal) study to corroborate the endoscopic findings and confirm the diagnosis of GERD (gastroesophageal reflux disease). In the absence of this comprehensive diagnostic evaluation, the medical necessity of revisional surgery is not established.