Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight Loss Surgery (43775)
The insurer denied: Weight Loss Surgery (43775)
The denial is overturned.

This patient is an adult female under consideration for bariatric surgery. At the time of the surgical evaluation, she was 61 inches tall and weighed 262 pounds. This corresponds to a body mass index (BMI) of 49.5. She has comorbid health conditions of hyperlipidemia, diabetes and hypertension.

The submitted documentation includes documentation of a surgical consultation. Nutritional notes document participation in a program with nutritional / exercise / behavioral components. This program was supervised by a registered dietician. Mental health clearance was provided. Medical clearance is provided.

Following completion of this evaluation, the patient was considered to be a suitable candidate for laparoscopic sleeve gastrectomy (CPT [Current Procedural Terminology] code 43775).

The requested weight loss surgery is medically necessary.

The health plan's denial letter notes, "weight loss surgery is medically necessary if all of the following preconditions apply: (1) the individual is at least 18 years old and is seeking coverage for an approved bariatric operation. The patient must also have a body mass index (BMI) of 40 or higher; or a BMI [body mass index] between 35-39.9 with at least one significant co-morbidity (e.g. Type 2 diabetes, hypertension, coronary artery disease etc.); (2) the individual presents acceptable documentation of active participation in a supervised weight management program and (3) the individual obtains a recommendation to perform surgery from a qualified surgeon, a separate medical evaluation recommending bariatric surgery and clearance for surgery from a mental health provider. There must also be documentation that the patient has been educated as to the risks and benefits after surgery and there is a treatment plan in place that addresses the person's needs before and after surgery."

This patient is an adult female that has a BMI (body mass index) in excess of 40, has weight-related comorbid health conditions that will respond favorably to the proposed bariatric surgery, and has actively participated in a supervised weight management program for six months. The submitted records do include a separate medical evaluation recommending bariatric surgery and clearance for surgery from a mental health provider. There is documentation that the patient has been educated as to the risks and benefits after surgery and there is a treatment plan in place that addresses the person's needs before and after surgery. This is detailed in the mental health assessment and in the surgical and nutritional notes.

There are numerous published reports in the peer-reviewed literature describing outcomes in patients after sleeve gastrectomy. There is greater than 5-year follow up data that is available to support the safety and efficacy of the sleeve gastrectomy procedure. The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 and excess weight loss ranging from 33% to 83%. [1,2,4,8]

Comorbidity resolution 12 to 24 months after sleeve gastrectomy has been reported numerous studies. These studies include 5-year data that demonstrates resolution rates of diabetes, hypertension, hyperlipidemia, and sleep apnea after sleeve gastrectomy that are comparable to results of other restrictive procedures. [1,2,4,8]

With supportive 5-year data and an affirmative position statement from The American Society for Metabolic and Bariatric Surgery (ASMBS), individual consideration should be given to selected patients who are contemplating this surgical approach. Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the patient's disease, is not deemed to be cosmetic or unproven, is proven to be more medically effective than any standard nonsurgical care and treatment and is not for the convenience of the patient or physician.

Therefore, given the above, the requested health service is medically necessary.