Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Surgical procedure on the stomach for future DOS
The insurer denied coverage for: Surgical procedure on the stomach for future date of service (DOS)
The denial is: Overturned
 
As per the medical record, the patient has suffered obesity for over 5 years and has an estimated body mass index (BMI) of 60.59 from a height of 4 feet 11 inches and a weight of 300 pounds. The patient suffers from morbid obesity, hypertension (HTN), obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP) and hypothyroidism. The patient has failed to achieve long-term weight loss and feels this patient is an excellent candidate for bariatric procedure.

Endocrine doctor noted in a letter that the patient has been under his care for hypothyroidism. This has been well controlled until late last year. 

Pulmonary function test (PFT's) showed patient feeling very intense shortness of breath (SOB) 7 out of 10 on the Borg scale.

Psychiatric evaluation done showed that the patient was a good candidate for bariatric surgery. The patient was motivated to achieve a significant weight reduction. The psychologist noted that the patient learned about bariatric surgery from sibling who had this surgery 4 years ago. The patient believes this surgery will give the opportunity to live a healthy life. The patient therefore found no current serious psych issues that would interfere with adherence to post-operative instruction. She supported the patient's decision to undergo bariatric surgery.

Pulmonology noted in a note that the patient was cleared for surgery. He recommended that the patient continue to undergo anticoagulation therapy as the patient had a history of pulmonary embolism (PE) and is currently on Eloquis. Sleep study done reveled severe obstructive sleep apnea (OSA) and recommended continuous positive airway pressure (CPAP).

The patient was seen for nutrition evaluation. The patient was counseled on diet. The anticipated adherence to diet was good. The patient was seen by cardiology who noted normal echocardiogram as well as labs. He felt the patient is optimized for bariatric surgery from a cardiology point of view. The patient was seen from pulmonary who noted no severe restriction on PFT's. He did note the severe OSA and the need to continue on CPAP.

The patient was seen who for the pre-operative bariatric prep visit. He noted the patient did the initial nutrition evaluation and follow-up. He noted the progress review with weights were completed. He noted the patient has been cleared by cardiology and pulmonary as well as hematology.  He recommended to the patient to undergo bariatric surgery and the preference was for biliopancreatic diversion with duodenal switch (BPD-DS). The patient will be scheduled for surgery.

Based upon the evidence in peer reviewed literature the reviewer disagrees with the insurer as the provider has provided documentation for the necessity of bariatric surgery. This patient is morbidly obese and meets all the criteria for bariatric surgery. The surgery that the provider is proposing is an approved procedure and there is evidence in improvement in health outcomes for this type of patient who is morbidly obese. This patient clearly meets indications for bariatric surgery and is a good candidate given the severe morbid obesity. This patient completed a multidisciplinary program and does meet The National Institutes of Health (NIH) requirements for bariatric surgery. This patient needs to lose weight and needs bariatric surgery so that they can improve their health. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a surgical procedure on the stomach at MS St. Luke's and Roosevelt for future DOS is substantiated.