Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity with gastric band surgery
Treatment: Lap band removal and sleeve gastrectomy (revision of prior bariatric surgery); codes 43775 and 43774
The insurer denied coverage for lap band removal and sleeve gastrectomy (revision of prior bariatric surgery); codes 43775 and 43774
The denial is upheld 

According to the documentation submitted, this is the case of an adult female with a history of hypertension, dyslipidemia, morbid obesity, and gastric band surgery. Per the office visit note from her Bariatric and General Surgeon, the patient was seen in the emergency department (ED) for food aspiration. Computed tomography (CT) showed dilated esophagus. Fluoroscopy esophagus function test showed mildly prominent cricopharyngeus muscle. The patient had Lap band filling and it was noted they would like to assess the band for potential removal versus revision to gastric bypass surgery. Another follow-up noted a repeat barium study after band deflation showed no esophageal dilatation and no suggestion of band slippage. Dysphagia and reflux with band were noted.

The National Institutes of Health (NIH) has indicated that bariatric surgery is appropriate for all patients with a body mass index (BMI) greater than forty, or for patients with a BMI of 35 to 40 with associated comorbid conditions. Obesity-related comorbidities are conditions that are directly caused by obesity or contribute to the severity of the condition. Obesity-related conditions include cardiovascular problems, diabetes mellitus, obstructive sleep apnea, asthma, musculoskeletal conditions, and various reproductive conditions. The requirements for patient selection for bariatric surgery include the appropriate BMI criteria failure of medical therapy. [1, 2]

The lap band procedure has become a popular weight loss procedure. However, long-term results and successful weight loss has been disappointing. Patients are known to have inadequate weight loss or weight regain after initial successful weight loss. Options for treatment of band complications or inadequate weight loss include band removal without any other intervention, band repositioning or replacement, revision to Roux-en-Y gastric bypass, or sleeve gastrectomy. In each case, band removal is required prior to any revisional surgery. [3, 4]

Band migration or slippage can lead to pouch dilatation and symptoms of dysphagia and gastroesophageal reflux disease (GERD). [5] Reduction in GERD symptoms after laparoscopic adjustable gastric banding (LAGB) have been conflicting. Some studies have demonstrated resolution of GERD symptoms, resolution of esophageal lesions, and a reduction of the postoperative DeMeester score after LAGB placement. Other studies have demonstrated the late development of GERD, which may be due to reduced esophageal clearance, pouch formation, food stasis, or reversible esophageal dilatation. [6, 7] First line therapy of GERD after a bariatric procedure is smoking and alcohol cessation. Second line therapy is the use of acid-reducing medications. [6] 

Per clinical documentation, the patient has a history of a lap band placement. The patient had successful weight loss after the procedure. The patient presented to an ED and noted to have malpositioned lap band. However, an upper endoscopy did not demonstrate any band erosions or malpositioning. It is also noted the patient has significant reflux. Medical records do not indicate that the patient is taking any medications for reflux. The patient's BMI was noted as 38. She has a recent diagnosis of hypertension and hydrochlorothiazide was started. There is no indication that the patient has failed medical management of her hypertension. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for lap band removal and sleeve gastrectomy (revision of prior bariatric surgery); codes 43775 and 43774 is upheld. Medical Necessity is not substantiated.