Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Gastroesophageal reflux disease (GERD). 
Treatment: Surgical Services (All). 
The insurer denied Weight-loss surgery and full hospital admission. 
The denial is overturned. 

This patient is a female under consideration for surgery to address the condition of gastroesophageal reflux disease (GERD) characterized by severe epigastric pain, heartburn, and bloating. While she initially lost 87 pounds (lbs) following sleeve gastrectomy, she has experienced some weight gain from her post-sleeve nadir. Current comorbid health conditions include hypertension, hypercholesterolemia, GERD, dysphagia, arthritis, and diabetes. She was treated for GERD with Pepcid and Prilosec. A contrast upper gastrointestinal (UGI) reported severe gastroesophageal reflux during the study, a small hiatal hernia, and anatomic changes of prior sleeve gastrectomy. The patient had consulted with a registered dietitian as part of an ongoing post bariatric surgery weight loss program. She has received counseling on diet and exercise. Her thyroid stimulating hormone (TSH) was normal. 
Following completion of this evaluation and due to ongoing symptoms of reflux in conjunction with anatomic changes of sleeve gastrectomy, her provider offered laparoscopic roux in Y gastrojejunostomy. 
At issue is the medical necessity of Weight-loss surgery and full hospital admission. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Weight-loss surgery and full hospital admission is medically necessary for this patient. 
The requested service (conversion to roux in Y gastric bypass and full hospital admission) is medically necessary and can be expected to be health beneficial for this patient. Roux in Y gastrojejunostomy as treatment of refractory GERD is a standard intervention for management of proven gastroesophageal reflux post sleeve gastrectomy. There is documentation of a complication of prior sleeve gastrectomy that is most appropriately addressed with the proposed revisional surgery. The patient has completed an evaluation for this complaint that confirms anatomic changes of the gastric sleeve and pathologic gastroesophageal reflux. The documentation provided does support that the proposed gastrojejunostomy is better than any alternative therapeutic options and is medically necessary for this patient's condition. This treatment will effectively divert gastric acid from the gastroesophageal junction and will resolve her symptoms of GERD. 

Standard surgical treatment of GERD for a non-bariatric surgical patient consists of crural re-approximation and fundoplication, magnetic sphincter augmentation with LINX, or endoscopic treatment. However, these treatments are not an option in this case given the specific surgical history. Conversion of the sleeve gastrectomy to roux in Y gastric bypass (RYGB) with gastrojejunostomy is the standard and accepted therapy for a patient with intractable GERD or bile reflux post sleeve gastrectomy. This treatment is consistent with published literature for the condition of refractory GERD/bile reflux post sleeve gastrectomy as is documented to exist in this case. Conversion to roux in Y gastric bypass is recognized as effective treatment of refractory GERD/bile reflux post sleeve gastrectomy within the bariatric surgical community based on outcomes data.
This type of surgery is typically performed in the hospital with an inpatient level of care. This inpatient status provides for surgical treatment and the medically necessary peri- and post-surgical care, intravenous (IV) fluid, antiemetics during diet progression and appropriate post-surgical monitoring. The intensity of service associated with perioperative bariatric care warrants an inpatient designation. 

Therefore, the requested health service/treatment of Weight-loss surgery and full hospital admission is medically necessary.