Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastro-esophageal reflux disease and prior laparoscopic sleeve gastrectomy
Treatment: Surgical Procedure on the Stomach; weight loss surgery (43644, 43281, 47563) x 1
The insurer denied coverage for Surgical Procedure on the Stomach; weight loss surgery (43644, 43281, 47563) x 1
The denial is upheld

This is an adult with a history of gastro-esophageal reflux disease (GERD) and laparoscopic sleeve gastrectomy. As per recent progress note the patient is post sleeve gastrectomy over 3 years ago, with preoperative maximum weight of 229 pounds. The patient had esophagogastroduodenoscopy (EGD) earlier this year which showed grade B esophagitis, and hiatus hernia. She started on twice daily proton pump inhibitors (PPI) and reported some improvement. She has daily nausea and frequent regurgitation, and she wishes to proceed with surgery. Her Body Mass Index (BMI) is approximately 20. The assessment was laparoscopic revision to gastric bypass and hiatal hernia repair. Ultrasound to rule out gallstones was to be done. 

The provider reviewed the sonogram results with patient. Ultrasound revealed cholelithiasis with no gall bladder wall thickening. EGD revealed Los Angeles classification (LA) Grade B esophagitis. Biopsy at the gastroesophageal (GE) junction revealed squamous esophageal and cardiac mucosa with active chronic cardio esophagitis. Negative for specialized columnar metaplasia. Plan was to repeat endoscopy in 3 months to evaluate for healing.

Based upon the records and Milliman Care Guidelines (MCG) as well references below, the patient does not meet the criteria and indications for weight loss surgery and does not meet the criteria to have a gastric bypass done for treatment of the GERD. The patient has a BMI of approximately 22 after a successful sleeve gastrectomy. She now reportedly has GERD. However, the only test that was documented in the records was EGD with Grade B esophagitis but no evidence of follow up with treatment. In addition, there is no ambulatory potential of hydrogen (pH) and no clear-cut evidence of a hiatal hernia. It is true that Gastric bypass is done for GERD in patients who have had previous sleeve and suffer from severe GERD. However, the reviewer does not see any evidence for an indication in this case.

This patient does NOT have morbid obesity so there is no indication for this surgery in this patient. 
	
Kahrilas (4) noted that in treating severe or frequent symptoms or erosive esophagitis they use a step-down therapy in patients with erosive esophagitis, frequent symptoms (two or more episodes per week), and/or severe symptoms that impair quality of life in order to optimize symptom relief. We begin with standard-dose PPI once daily for eight weeks in addition to lifestyle and dietary modification. Schwaitzberg (5) noted that lifestyle modification and medications are the first-line treatment for GERD. Surgical management is generally reserved for patients who have persistent symptoms or develop complications despite optimal medical therapy. Additionally, patients who are unable to tolerate, noncompliant with, or unwilling to take lifelong medications are also surgical candidates. In addition, it was noted that a consensus panel recommended that upper endoscopy, standard pH testing, esophageal manometry, and barium esophagram be performed for all patients before anti reflux surgery. In this case there is not any indication for the surgical procedure in the form of gastric bypass to be used in this patient at the present time. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Surgical Procedure on the Stomach; weight loss surgery (43644, 43281, 47563) x 1 is not substantiated.