Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Weight Loss Surgery(laparoscopy sleeve gastrectomy), Pre-service
The insurer denied the Weight Loss Surgery(laparoscopy sleeve gastrectomy)
The denial is overturned. 

The patient is a woman under consideration for bariatric surgery. Body mass index (BMI) of 42.6 kg/m2 (kilograms per meters squared). The records indicate that she has been obese for at least the past several years.  The patient has a long history of prior weight loss efforts that have not been successful. These efforts are detailed in the letter of medical necessity.  While she has attempted to lose weight with conventional programs, she has remained with morbid obesity.

The patient sought evaluation for evaluation for bariatric surgery.  She was entered into a multidisciplinary bariatric program. She has consulted with a psychologist.  The patient has been cleared for bariatric surgery from a mental health standpoint. The patient consulted with a dietician and was counseled and educated on the nutritional changes necessary with sleeve gastrectomy.

The patient's thyroid function (TSH) was normal.  She followed a supervised weight loss program.  The patient also has completed medical evaluation with her primary care provider and was cleared for the proposed bariatric surgery.  Cardiology consultation was completed and she was cleared for the proposed surgery.  Pulmonary consultation and clearance was obtained.

Following this evaluation and because of persistent morbid obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy, CPT 43775).

The health plan rationale for denial per the letter is that there is not documentation of attempted weight loss without surgery, no documentation of a medically supervised weight loss program for at least six-months, and no documentation of diet, exercise and other health issues.

Yes, the sleeve gastrectomy and the associated inpatient admission are medically necessary based on the submitted clinical data and generally accepted standards of care.

The health plan did not act with sound medical judgment or in a manner consistent with the accepted standard of care.  Laparoscopic Sleeve Gastrectomy (LSG) will be more beneficial than any alternative non-surgical weight loss program for the treatment of this patient's morbid obesity.  There are numerous published reports in the peer-reviewed literature describing outcomes in patients after sleeve gastrectomy. There is greater than five-year follow up data that is available to support the safety and efficacy of the sleeve gastrectomy procedure.  The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 kg/m2 (kilograms per meters squared) and excess weight loss ranging from 33% to 83%.

Comorbidity resolution 12 to 24 months after sleeve gastrectomy has been reported numerous studies.  These studies include five-year data that demonstrates resolution rates of diabetes, hypertension, hyperlipidemia, and sleep apnea after sleeve gastrectomy that are comparable to results of other restrictive procedures.

With supportive five-year data and an affirmative position statement from The ASMBS (American Society for Metabolic and Bariatric Surgery), individual consideration should be given to selected patients who are contemplating this surgical approach.  Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the patient's disease, is not deemed to be cosmetic or unproven, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the patient or physician.

The health plan rationale for denial per the letter is that there is not documentation of attempted weight loss without surgery, no documentation of a medically supervised weight loss program for at least 6-months, and no documentation of diet, exercise and other health issues.   The submitted Anthem Clinical UM Guideline for Bariatric surgery does not mandate documentation of a medically supervised weight loss program for at least six-months. The requirement that a patient have weight related comorbid illnesses of a certain arbitrary severity (particularly in the setting of a BMI [body mass index] > 40 kg/m2 [kilograms per meters squared]) is not consistent with nationally recognized standards.

The proposed sleeve gastrectomy is medically necessary for her and is consistent with the standard of care. The requested service laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient for the following reasons:

(i)	  The patient meets the widely accepted NIH (National Institutes of Health) and The American Society for Metabolic and Bariatric Surgery (ASMBS) criteria to undergo bariatric surgery including the LSG (laparoscopic sleeve gastrectomy) procedure (BMI [body mass index] of 42.6 kg/m2 [kilograms per meters squared], failed nonsurgical efforts to promote weight loss.

(ii)	The patient has been evaluated by a multidisciplinary bariatric program.  She has been counseled regarding the necessary post-surgical nutritional and lifestyle changes and she has been granted mental health clearance.  She has been granted medical, psychological and surgery clearance.

(iii)   The LSG (laparoscopic sleeve gastrectomy) procedure is not unproven.  It has garnered the support of ASMBS (American Society for Metabolic and Bariatric Surgery) guidelines and has proven efficacy and weight loss comparable to other bariatric procedures.

This patient is an appropriate candidate for LSG (laparoscopic sleeve gastrectomy). She has been evaluated by a multidisciplinary bariatric program with nutritional and psychological consultations and she satisfies ASMBS (American Society for Metabolic and Bariatric Surgery) and NIH (National Institutes of Health) weight/BMI (body mass index) criteria for consideration for bariatric surgery including LSG (laparoscopic sleeve gastrectomy).  LSG (laparoscopic sleeve gastrectomy) is medically necessary for this patient, and this procedure is likely to be health beneficial for her.