Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid obesity 
Treatment: Inpatient Surgery (43860 x 1, 43659 x 1); repeat bariatric surgery
The insurer denied coverage for inpatient surgery; repeat bariatric surgery.
The denial is upheld.

This patient had a gastric banding done previously. The justification for that procedure has not been presented to this reviewer. There are no details. The records begin in the last couple years when he is being seen for failure of weight loss, regain and complications, namely gastroesophageal reflux disease (GERD). 

The symptoms and workup for GERD have not been provided to this reviewer. It is stated that he had lost 90 pounds. The pouch was dilated (overhanging the band) and that delayed emptying was observed somehow. Nowhere is there mention of an esophagogastroduodenoscopy (EGD). The only treatment was Prilosec 40 milligrams (mg) daily. There is no other treatment suggested per these records. Nonetheless the band and port were removed over a year ago and he has of course gained weight. He is now at 358 pounds with a body mass index body mass index (BMI) of 51.4.

The requesting provider is appealing a denial of a request to perform a repeat bariatric procedure. This he labels as a one anastomosis gastric bypass (OAGB) or mini bypass. He provides the first page of two articles supporting the procedure. 

What little history has been provided suggests to this reviewer, as an experienced bariatric surgeon, is that the band did not fail the patient, but the patient failed the band. He lost 90 pounds, developed GERD which is not unusual with the band. The reflux can be quite severe with laryngopharyngitis and aspiration pneumonia. The pouch dilated massively, thus the delayed gastric emptying. The fact that the pouch so markedly enlarged is because the patient was over-eating the bariatric procedure. This patient, on the basis of what little history has been provided is not a candidate for surgical assisted weight loss. The tried-and-true gold standard Roux-en-Y gastric bypass (RYGB). It will treat his GERD as well as assist him in weight loss if he works with it.

Presented were several articles regarding the OAGB. It is to be noted that virtually none of the articles are from studies in the United States. Most are from Europe and the Orient. It is a faster and easier procedure as he has stated. The complications are less than the standard RYGB. However, aside from an anastomotic leak, the most common complication is gastroesophageal reflux. There is most often greater weight loss with the OAGB than with the RYGB but there is a higher incidence of nutrition deficiencies, bile gastritis, GERD, and abdominal pain due to bile gastritis. 

All the articles end with language suggesting that more studies need to be done. A relatively high percentage of the patients having had this procedure are said to have to have revision because of the bile gastritis and GERD. One study reviewed gave results out 5 years; most are 2-3 years.

In sum, this patient is not a candidate for bariatric surgery. The undesirable side effects are problematic, one of which is what he is trying to treat, GERD.     

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of inpatient surgery (43860 x 1, 43659 x 1); repeat bariatric surgery should be upheld.