Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Surgical procedure on the stomach (inpatient weight loss surgery, 43860 x 1)
The insurer denied coverage for surgical procedure on the stomach (inpatient weight loss surgery, 43860 x 1)
The denial is overturned
 
As per the medical records, this is an adult who was seen on via telehealth platform. She noted the patient presented for obesity medicine follow up. She reported no change in her weight since her last visit. Her current weight was 266. She noted that 2 weeks ago she broke her left tibia thus decreasing her mobility. She is pursuing gastric bypass revision. She has diabetes with her most recent glycated Hemoglobin (HgbA1C) being 5.7.  She noted the patient is eager to pursue medically supervised weight loss and would like to start medication for help. She noted the past medical history of coronary artery bypass grafting x 1.

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC)  the procedure is indicated by ALL of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: Patient has Body Mass Index (BMI) of 40 or greater, or  adolescent patient (13 to 17 years of age) has BMI of 40 (or 140% of the 95th percentile in an age and sex matched growth chart) or greater, or Patient has BMI of 35 or greater and clinically serious condition related to obesity (type 2 diabetes, obesity hypoventilation, nonalcoholic steatohepatitis, pseudo tumor cerebri, severe osteoarthritis, difficult to control hypertension), or adolescent patient (13 to 17 years of age) has BMI of 35 (or 120% (percent) of the 95th percentile in an age and sex matched growth chart) or greater and a clinically serious condition related to obesity (type 2 Diabetes, obstructive sleep apnea, nonalcoholic steatohepatitis, pseudotumor cerebri, Blount disease (tibia vara), slipped capital femoral epiphysis), or Adult patient has BMI of 30 or greater with type 2 diabetes mellitus with inadequately controlled hyperglycemia despite optimal medical treatment (oral medication, insulin).

This patient does meet criteria for revision surgery. She has a BMI greater than 40 and has met the requirements for weight loss surgery. In addition, there is literature for revision of gastric bypass with distalization and revision of the gastrojejunostomy anastomosis which does provide adequate results in terms of weight loss. Revision surgery is usually done for complications such as fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, stricture, documented gastroesophageal reflux disease (GERD) or pouch enlargement. In this case there is dilation of gastrojejunostomy anastomosis with a normal size pouch- which can also lead to weight regain. Because of this dilation of the anastomosis over time she is now regaining weight. She has been compliant as per her bariatric surgeon with diet and exercise and now needs a revision of the surgery that was done many years ago. This is not due to a patient failure but due to failure of the anastomosis with time. Revisional surgery should be approved in this case.
	
Based on the above, the insurer's denial must be overturned. 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 surgical procedure on the stomach (inpatient weight loss surgery, 43860 x 1) is substantiated.