Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity.
Treatment: Revision of previous weight loss surgery.
The insurer denied coverage for revision of previous weight loss surgery.
The denial is upheld.

According to the documentation provided, this is an adult female with a history of morbid obesity. She presented for a telemedicine visit for a presurgical visit after completing surgical requirements. The provider noted in a clinic visit note that the patient is status post-sleeve gastrectomy. She has been unable to sustain weight loss. He noted that over time her ability to take larger portions has increased. She also complains of gastroesophageal reflux disease (GERD). Her body mass index (BMI) was 40. The plan was to undergo sleep apnea testing, and psychological testing as well as meet the nutritionist. She represented a few weeks later to complete her presurgical requirements. Her BMI was 39.5.

The provider noted that the patient had a transient ischemic attack (TIA) last month and she is now going for physical therapy (PT) for left-sided weakness. Her BMI was now 38.9. The provider saw the patient approximately 7 months later and noted she was being seen to complete her presurgical requirements. She has seen the nutritionist and is working on her diet. Her weight was 234 pounds. The patient was seen for a nutrition consult. The provider noted the patient has been through this process before but was pregnant last year so she could not go through with the surgery. The bariatric nutrition protocol was reviewed with the patient. The provider saw the patient over 1 month later. Her BMI was 38.6. She was post-psych (psychiatric) eval and support group x 2. 

The provider saw the patient again and noted the patient continued to lose weight. She was exercising consistently. She was seen for a nutrition follow-up. Her BMI was 38.7. The patient was looking for a date for surgery.

Prior notes for the original sleeve gastrectomy were also submitted and reviewed. It was noted that before surgery her BMI was 42.1. Postop from her sleeve gastrectomy BMI was 37.93. No other records were provided. 

A letter of medical necessity notes that the patient has been under medical care and has long-standing morbid obesity. The patient has attempted weight loss including seeing a nutritionist, lower calorie diets, and eliminating fried greasy food. The patient has obstructive sleep apnea (OSA), and osteoarthritis. The provider fully recommends this patient's decision to pursue weight loss surgery.

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does not meet the criteria and indications for revision of bariatric surgery. There is no documentation that the patient has had complications related to her sleeve gastrectomy with stenosis and stricture at the incisura leading to gastric distension associated with nausea and vomiting or with pouch dilation. There is no evidence that the patient was compliant following the original sleeve gastrectomy to justify a revision of the sleeve. The endoscopy performed did not show any evidence of pouch dilation or stricture or severe GERD to warrant revision of the sleeve gastrectomy.

This patient has a BMI that has been around 38 to 39 and there has been no documentation of comorbidities that would warrant revision bariatric surgery. The patient was indeed cleared by cardiology, psychology and as well as by nutrition- however, there was no documentation that the prior sleeve gastrectomy had a complication requiring revision. Therefore, the patient does not meet the guidelines for bariatric surgery for this patient.

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

The insurer's denial of coverage for revision of previous weight loss surgery is upheld. Medical Necessity is not substantiated.