Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity.
Treatment: Surgical Procedure on the Stomach (sleeve gastrectomy) and hospital admission.

The insurer denied coverage for Surgical Procedure on the Stomach (sleeve gastrectomy) and hospital admission.  The denial is overturned. 

This is a male patient with a history of morbid obesity, Obstructive Sleep Apnea (OSA), high cholesterol, and adjustment disorder, unspecified.  He was recommended to undergo preoperative evaluation for weight loss surgery.  The provider felt the patient was an appropriate candidate for weight loss surgery.  The patient was felt to be a suitable candidate of bariatric surgery based on BMI of 54.63.  The patient was previously seen for a nutrition evaluation for bariatric surgery and was felt at that point in time as well to be a good candidate for bariatric surgery.

The patient underwent esophagogastroduodenoscopy (EGD), at which time a normal esophagus was documented with benign appearing gastric polyps noted.  An ultrasound of the abdomen revealed enlarged echogenic liver, compatible with nonspecific parenchymal disease.  There was no cholelithiasis.  It was noted in a preoperative weight loss program note that the patient had undergone weight management in a medically supervised manner over a period of several months.  This included periodic visits with weigh in, education regarding diet and ongoing discussion regarding the importance of physician activity and exercise. 

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does meet the criteria and indications for bariatric surgery and the procedure is medically necessary as well as the hospital admission.  The patient has a BMI of 58 that would warrant bariatric surgery.  He therefore does meet the criteria set forth by MCG guidelines, as he met guidelines as noted below.

The patient meets the guidelines for inpatient surgery as sleeve gastrectomy is performed on an inpatient basis.  According to MCG Health Inpatient and Surgical Care 24th Edition Gastric Restrictive Procedure, sleeve gastrectomy by laparoscopy, the procedure is indicated by all of the following: Severity of obesity judged appropriate for procedure as indicated by 1 or more of the following: Patient has BMI of 40 or greater or Patient has BMI of 35 or greater and clinically serious condition related to obesity or Adult patient has BMI of 30 or greater with type 2 diabetes mellitus with inadequately controlled hyperglycemia despite optimal medical treatment; 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, Patient has demonstrated reliable participation in preoperative weight-loss program that is multidisciplinary; Current substance abuse not identified; Expectation that patient will be able to adhere to postoperative care; 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.  This patient has a BMI of 58 and did undergo psychiatric evaluation as well as nutrition evaluation and took part in a multi-disciplinary weight loss program.  As per MCG, the Operative Status Criteria is inpatient with the goal length of stay being 1 day; thus the hospital admission is justified.  Therefore, the patient did meet criteria for weight loss surgery and for admission.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for Surgical Procedure on the Stomach (sleeve gastrectomy) and hospital admission is substantiated.  The insurer's denial is overturned.