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

Physician 1: The patient is a 40-year-old female with a body mass index (BMI) of 42 and multiple comorbidities. She has passed medical, surgical and psychological evaluations and requested authorization and coverage for laparoscopic restrictive vertical gastroplasty/lateral sleeve gastrectomy. The Health Plan has denied this request indicating that the efficacy of the requested procedure remains unproven.Restrictive vertical gastroplasty/LSG is a component of the pancreaticobiliary bypass with duodenal switch (PBB/DS) procedure. This procedure is generally appropriate as the first component of a staged PBB/DS in a super morbidly obese patient (BMI greater than 60). There are scattered reports of LSG as sole surgical therapy, however, there is no consistent randomized data to support the efficacy of that application. The American Society of Bariatric Surgeons (ASBS) does not recognize restrictive vertical gastroplasty/vertical sleeve gastrectomy as an isolated bariatric procedure and it is not considered the standard of care.  With a BMI of 42, the patient would benefit from the standard surgical weight loss procedures. Accordingly, 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 2: The patient is a 40-year-old female with a body mass index (BMI) of 42 and multiple comorbidities including degenerative joint disease, hypertension, dyspnea, mild sleep apnea and depression. She had a positive psychological evaluation and is a clear candidate for bariatric surgery. The patient has researched the surgical alternatives and wishes to avoid the potential complications of malabsorption by undergoing a vertical sleeve gastrectomy (VSG). 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.A review of the current data shows the VSG procedure has an acceptable success rate and risk profile and comparable success in terms of excess body weight loss. There is no malabsorptive component to this procedure, and the data argues that this alternative offers potential advantages with regard to the patients concerns.  It is a medically reasonable alternative in this case. Therefore, 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 3: The patient is a 40-year-old female who is 56 tall, weighs 262 pounds and has a BMI of 42.3. She has multiple comorbid conditions including hypertension, degenerative joint disease, depression and mild sleep apnea and meets the accepted criteria for weight loss surgery. After considering the available surgical options, the patient wishes to undergo laparoscopic restrictive vertical gastroplasty/vertical sleeve gastrectomy. The Health Plan has denied authorization and coverage for this procedure citing the lack of peer-reviewed scientific literature supporting its efficacy.It is nearly impossible to perform any randomized surgical trial to compare two procedures head to head for outcome, complications, and efficacy.  The scientific community relies on large data sets as the basis for outcome and efficacy determinations when it relates to a surgical procedure. This information is lacking in the case of laparoscopic restrictive vertical gastroplasty/vertical sleeve gastrectomy and there is no basis for a conclusion that the requested procedure is superior in efficacy to Roux-en-Y gastric bypass or the duodenal switch procedure. The three forms of bariatric surgery currently supported by American Society for Bariatric Surgery and National Institutes of Health are Roux-en-Y gastric bypass, adjustable silicone banding (Lap-Band) and the PBB/DS. I agree that long-term data on the efficacy of vertical gastrectomy is lacking and 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.