Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Morbid Obesity

Treatment: Biliopancreatic diversion with duodenal switch and inpatient admission

The insurer denied coverage for biliopancreatic diversion with duodenal switch and inpatient admission.

The denial is overturned.

This is a patient with morbid obesity, hypertension and obstructive sleep apnea (OSA). In an undated note, the patient's body mass index (BMI) is noted to be 63 and his weight is 440 pounds. Most recently, the patient was noted to be 315 pounds. The patient presented for evaluation for bariatric surgery. The patient has been approved by bariatric surgeon, pulmonary, the registered dietitian (RD) and psychology. Request for the procedure has been made.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The peer reviewed literature shows the following: While several patients developed nutrient deficiencies, Single Anastomosis Duodeno-Ileostomy with Sleeve gastrectomy (SADI-S) seems to be an overall safe and effective bariatric operation.

The American Society for Metabolic and Bariatric Surgery (ASMBS) has reached the conclusion that SADI-S (Single Anastomosis Duodeno-Ileostomy with Sleeve) provides for similar outcomes to those reported after classic duodenal switch (DS) and should therefore be endorsed, similar to the ASMBS' endorsement of the predicate procedure of biliopancreatic diversion with duodenal switch (BPD/DS). SADI-S, a modification of classic Roux-en-Y DS (duodenal switch), is therefore endorsed by ASMBS as an appropriate metabolic bariatric surgical procedure.

Therefore, the procedure is safe and effective and results in an improvement in health.

Biliopancreatic diversion with duodenal switch and inpatient admission has final approval from the appropriate regulatory bodies for this diagnosis. The procedure is endorsed by the ASMBS (American Society for Metabolic and Bariatric Surgery) as being safe and effective.     

This patient is a good candidate for biliopancreatic diversion with duodenal switch (BPD-DS) and inpatient admission. This patient has morbid obesity and is a good candidate for bariatric surgery including the single anastomosis duodenal switch. This patient has morbid obesity, hypertension and obstructive sleep apnea (OSA). The patient has been approved by bariatric surgeon, pulmonary, the registered dietitian (RD) and psychology.     

This procedure is safe and effective with less side effects than traditional BPD-DS (biliopancreatic diversion with duodenal switch). Therefore, the procedure is considered to be medically necessary and is the best available treatment for this patient at this time.     
  
The adverse risks are not increased over standard treatment services. This is safe, effective with decreased side effects compared to BPD-DS (biliopancreatic diversion with duodenal switch). Therefore, the risks are not more increased.     

This patient has significant morbid obesity with obstructive sleep apnea and hypertension. These comorbid conditions as well as the morbid obesity places the patient at a significant health risk. The SADI-S (Single Anastomosis Duodeno-Ileostomy with Sleeve) will provide that benefit with less risk of complications.  

In summary, the denial of biliopancreatic diversion with duodenal switch and inpatient admission and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.