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

Physician 1: The patient is a 47-year-old male with a body mass index (BMI) of 36.3. He has multiple comorbidities. Upon consideration of the available surgical options, the patient has decided that he wishes to undergo laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied authorization and coverage for this procedure on the basis that there is insufficient peer-reviewed scientific literature supporting its efficacy.Vertical gastroplasty/gastrectomy is a useful bariatric procedure in patients with BMIs between 35 and 40 or as a first stage procedure in patients who are super morbidly obese. The requested procedure has an acceptable success rate and risk profile. Hence, it is a medically reasonable alternative in this case. For these reasons, I have determined that 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.Physician 2: The patient is a 47-year-old male with a body mass index (BMI) of 36. He has multiple comorbidities. He has requested authorization and coverage for  laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied this request indicating that the efficacy of the requested procedure remains unproven. Restrictive vertical gastroplasty/gastrectomy is generally appropriate as a component of a staged procedure in the super obese (BMI greater than 60). The patient does not fall within this group of patients. As an isolated procedure, there are no large studies to confirm its long-term efficacy. The American Society of Bariatric Surgeons does not recognize restrictive vertical gastroplasty/gastrectomy as an isolated bariatric procedure. Furthermore, the requested procedure does not fall within the Health Plan guidelines of approved bariatric procedures.The patient can be appropriately treated with standard surgical weight loss procedures. As such, I have determined that 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 47-year-old male requesting authorization for laparoscopic restrictive vertical gastroplasty/gastrectomy. The patient reports that at 510 his weight is 253 pounds resulting in a body mass index (BMI) of 36.3. The patient also reports multiple comorbidities including diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease (GERD), probable sleep apnea, and degenerative joint disease. The patient has completed pre-operative workup including psychological evaluation. The patient wishes to undergo restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied coverage for this procedure on the basis that it is considered experimental/investigational.Restrictive vertical gastroplasty/gastrectomy differs from vertical-banded gastroplasty (VBG), which is referenced in the Health Plans medical policy on obesity surgery. With VBG, a synthetic mesh is utilized to create a very narrow stomach pouch. It has a very high failure rate and very few surgeons currently perform the procedure. Restrictive vertical gastroplasty/gastrectomy does not utilize synthetic mesh; with this procedure, the majority of the stomach is removed from the abdominal cavity. In any event, there is no long-term data demonstrating that restrictive vertical gastroplasty/gastrectomy is superior in efficacy to Roux-en-Y gastric bypass or the duodenal switch procedure. Therefore, I have determined that 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.