Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Weight loss surgery (roux-en-Y with duodenal switch)
The insurer denied the Weight loss surgery (roux-en-Y with duodenal switch)
The denial is overturned

The patient is a female who is seeking surgical treatment for the condition of morbid obesity.  The patient has a current body mass index of 50 kilograms per meter squared (kg/m2) with weight related comorbid health conditions of multiple arthropathies, hypertension, high cholesterol, and pre-diabetes.  

The patient consulted with the provider for the condition of refractory morbid obesity.  The patient was enrolled in a comprehensive multidisciplinary bariatric program.  She has been granted medical clearance.  The patient participated with a supervised nutrition program.  A behavioral health evaluation was completed with mental health clearance for the proposed bariatric operation.

The Health Plan denial letter states that the requested procedure (duodenal switch) is not a proven therapy for this patient's condition and therefore is not a coverage benefit.

Yes, the proposed treatment is medically necessary.
The proposed procedure is a medically necessary intervention for this patient with super morbid obesity (body mass index [BMI] 50 kilograms per meter squared).  Bariatric Surgery as proposed is a proven effective therapy for individuals with a body mass index greater than 40 or a body mass index greater than 35 with comorbid health conditions who have successfully completed a comprehensive pre-surgical evaluation.  

In this case the proposed procedure (duodenal switch) is a medically necessary treatment for the documented condition of medically complicated morbid obesity with a body mass index of 50 kilograms per meter squared and is supported by the most recent guidelines published by the American Society for Metabolic and Bariatric Surgery. [1]. This patient has successfully completed a comprehensive multidisciplinary bariatric evaluation with medical, surgical, nutritional and mental health components.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This procedure (duodenal switch) is a generally accepted treatment for the condition of medically complicated morbid obesity as is documented to exist in this case.  It is effective as supported by multiple peer reviewed publications.  It is not the part of any ongoing clinical trial.  The published guidelines of the American Society for Metabolic and Bariatric Surgery support the safety and efficacy of the duodenal switch procedure for a patient such as this patient.  This procedure does not require Food and Drug Administration (FDA) approval.

Based on the published literature, the proposed bariatric operation [duodenal switch] is medically necessary for the insured's condition/disease.

This patient has a body mass index (BMI) of 50 kilograms per meter squared with weight related comorbid health conditions of hypertension, high cholesterol, arthropathy, and pre-diabetes.  The proposed treatment in this case is the duodenal switch procedure.  This procedure is proposed as a bariatric operation to achieve weight loss and ameliorate comorbid health conditions.  

The most recent guideline or statement regarding this proposed procedure from the American Society for Metabolic and Bariatric Surgery was published in 2020. [1]  The conclusion of this updated guideline is that there is an adequate volume of peer reviewed publications that report data on approximately 1500 patients and that this procedure is an endorsed procedure per the American Society for Metabolic and Bariatric Surgery.

This procedure is provided in accordance with generally accepted standards of medical practice.  It is clinically appropriate and considered effective for the patient's condition.  It is not for the convenience of anyone.