Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity; Obstructive sleep apnea (OSA),

Treatment: 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)

The insurer denied coverage for 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less). The denial was reversed.

This patient is a female with a history of obesity, obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension (HTN) and diabetes mellitus type -2, diverticulosis, who presented for bariatric surgery consultation. It was noted that the patient was seeking seeks a surgical solution and further dietary guidance for longstanding weight issues and associated comorbidities.  Previous attempts at weight loss on their own have been without lasting success. Initial onset of obesity was as a child. Co-morbidities include hyperlipidemia, abdominal obesity diabetes, hypertension, sleep apnea, thyroid disease, depression and metabolic syndrome. Diets tried in the past include Eating for life, protein diets.  Weight pattern includes weight of 169 pounds and maximum weight loss of 30 pounds.  The patient exercises infrequently.  The patient utilizes continuous positive airway pressure (CPAP) machine with regard to her sleep apnea.  

The issue that is raised here is whether the 43644 laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) and the inpatient hospital admission is medically necessary for this patient.
Based upon the records provided and MCG guidelines, the patient does meet the criteria and indications for bariatric surgery for gastric bypass.  At most the patient has a BMI of 32.88.  She does have diabetes with HbA1-C as high as 9 in documents provided.  Thus, based upon the guidelines of MCG she does meet criteria for bariatric surgery.

The patient is candidate for bariatric surgery as indicated by ALL of the following: Failure to achieve and maintain significant weight loss with nonsurgical treatment, Correctable cause for obesity not identified (e.g., endocrine disorder), Patient has demonstrated reliable participation in preoperative weight-loss program that is multidisciplinary (e.g., low-calorie diet, supervised exercise, behavior modification); Current substance abuse not identified; Patient is fully grown or nearly fully grown; Expectation that patient will be able to adhere to postoperative care (e.g., judged to be committed and able to participate in postoperative requirements); Patient is receiving treatment in multidisciplinary program experienced in obesity surgery that can provide ALL of the following:  Surgeons experienced with procedure, Preoperative medical consultation and approval, Preoperative psychiatric consultation and approval, Nutritional counseling, Exercise counseling, Psychological counseling, Support group meetings.  The patient has a BMI that would meet criteria as her BMI is greater than 30 with uncontrolled diabetes with very significant HbA-1C.
To summarize, coverage should be provided for bariatric surgery in this patient using gastric bypass given her BMI of 32 and uncontrolled diabetes.  The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) and the inpatient hospital admission is reversed.  The medical necessity is substantiated.