Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approvea hiatal hernia repair. We decided that the Plan does not have to pre-approvea conversion of sleeve gastrectomy. You asked the Plan to pre-approvea hiatal hernia repair. You say that the requested services are needed not due to obesity but to dysphagia and vomiting.The Plan says that the enrollee does not meet criteria for the requested bariatric surgery procedure.We decided that the Plan has to pre-approvea hiatal hernia repair. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. Items and services that are not medically necessary are not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a hiatal hernia repair. Our reviewer says that the request for a hiatal hernia repair meets criteria for medical necessity. Our physician reviewer found that the record indicates that enrollee has previously had a sleeve gastrectomy and has dysphagia and vomiting.The enrollee has a hiatal hernia. The surgicalnote from April 2021 indicates that based upon the normal manometry, the enrollee is most likely to benefit from hiatal hernia repair.The provided records support the medical necessity and reasonableness of the hiatal hernia repair (43281).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hiatal hernia repair have been met.Therefore, we decided that the Plan has to pre-approvea hiatal hernia repair(43281). We also decided that the Plandoes not have to pre-approvea conversion of sleeve gastrectomy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a conversion of sleeve gastrectomy. Our reviewer says that the request for a conversion of sleeve gastrectomy does not meet criteria for medical necessity. Our physician reviewer found that that the enrollee is most likely to benefit from hiatal hernia repair, not conversion of the sleeve gastrectomy.The record does not support the medical necessity and reasonableness of conversion to a Roux Y bypass (43645). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a conversion of sleeve gastrectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvea conversion of sleeve gastrectomy(43645).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.