Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Sleeve Gastrectomy Surgery (CPT 43775)

The insurer denied Sleeve Gastrectomy Surgery (CPT 43775).  The denial is overturned.

This patient is an adult female under consideration for bariatric surgery. She was 64 inches tall and weighed 220 pounds. This corresponds to a body mass index (BMI) of 37.8 kilograms per meter squared (kg/m2). Her obesity related comorbid conditions include hypertension, for which she is prescribed Lisinopril. The patient has a history of prior weight loss efforts that have not been successful. While she has attempted to lose weight, she has remained with medically complicated morbid obesity.
The patient sought evaluation for bariatric surgery. She was entered into a multidisciplinary bariatric program. The patient has consulted with a psychiatrist and has been cleared for bariatric surgery from a mental health standpoint per the evaluation. She completed nutritional evaluation with a registered dietician. Her thyroid stimulating hormone (TSH) was normal. A medical assessment was done. Following this evaluation and because of persistent morbid obesity the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy). The health plan rationale for denial is that the patient has a body mass index of 38 kilograms per meter squared but does not have a qualifying comorbid health condition (diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis (NASH), pseudotumor cerebri, severe osteoarthritis, uncontrolled hypertension). In the absence of associated qualifying comorbidities, sleeve gastrectomy is not medically necessary.

The proposed sleeve gastrectomy is medically necessary for this patient.

Sleeve gastrectomy, as proposed in this case, is in accordance with generally accepted standards of medical practice, is clinically appropriate, and is not for the convenience of anyone. Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed laparoscopic sleeve gastrectomy is medically necessary for this patient. This patient has a body mass index in excess of 35 kilograms per meter squared with weight related comorbid health conditions that include hypertension for which she is prescribed Lisinopril. She has successfully completed a multidisciplinary bariatric evaluation. Laparoscopic sleeve gastrectomy is medically necessary for this patient, per widely accepted guidelines, as her body mass index is in excess of 35 kilograms per meter squared, and she has successfully completed a comprehensive pre-surgical bariatric evaluation. [1] The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a medical and mental health standpoint, per the enclosed psychological and medical evaluations. From the available data, it can be expected that laparoscopic sleeve gastrectomy would be health beneficial for this patient and that she meets generally accepted 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery criteria for the proposed bariatric operation. [1] These most recent published guidelines for bariatric surgical patient selection support that bariatric surgery is proven effective therapy for appropriately selected patients with body mass index of at least 35 kilograms per meter squared with or without comorbid illness (as in this case) or a body mass index of at least 30 kilograms per meter squared with weight related illness. Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy. This patient's condition warrants treatment as is proposed, and this treatment would be expected to be health beneficial for her and is consistent with internationally accepted guidelines of care. [1]