Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity.
Treatment: Weight Loss Surgery (43770).

The insurer denied Weight Loss Surgery (43770).  The denial is overturned.

This patient is an adult female under consideration for bariatric surgery. The patient was 64 inches tall and weighed 186 pounds. This corresponds to a body mass index (BMI) of 32 kilograms per meter squared (kg/m2). The patient has comorbid health conditions of sleep apnea, for which continuous positive airway pressure (CPAP) has been prescribed. She is also reported to have gastroesophageal reflux disease (GERD). The patient has attempted weight loss with conventional weight loss programs, such as Weight Watchers. However, she has not been successful with significant sustained weight loss. The patient sought evaluation for bariatric surgical consultation. The records indicate that the patient was entered into a multidisciplinary bariatric program. A telemedicine pulmonary consultation was performed. Per this consultation, the patient had a home sleep study that revealed moderate obstructive sleep apnea with an apnea hypopnea index [AHI] of 18. Continuous positive airway pressure (CPAP) was prescribed. Psychological evaluation provides mental health clearance. The patient consulted with a registered dietician and received nutritional counseling and education. Preoperative cardiovascular clearance was granted per consultation. Medical clearance was granted by the Provider. Thyroid stimulating hormone (TSH) was normal. 

The proposed weight loss surgery (43770) is medically necessary.

Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed laparoscopic adjustable gastric band (LAP BAND) procedure is medically necessary for this patient. 

The patient has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical, pulmonary and cardiology clearance. Laparoscopic adjustable gastric band (LAP BAND) is medically necessary for this patient per widely accepted guidelines as her body mass index (BMI) is in excess of 30 kilograms per meter squared (kg/m2) in association with weight related illness of sleep apnea. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical evaluation and is felt to be an acceptable candidate for the proposed surgery. From the available data it can be expected that laparoscopic adjustable gastric band (LAP BAND) would be health beneficial for this patient and that she meets generally accepted 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery criteria for the proposed bariatric operation. [1]. The most recent published guidelines for bariatric surgical patient selection support that bariatric surgery is proven effective therapy for appropriately selected patients with body mass index of at least 35 kilograms per meter squared (kg/m2) with or without comorbid illness or a BMI of at least 30 kilograms per meter squared (kg/m2) with weight related illness (as in this case). Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy. This patient's condition warrants treatment as is proposed and this treatment would be expected to be health beneficial for her and is consistent with internationally accepted guidelines of care. [1]