Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve laparoscopy, surgical, gastric restrictive procedure (CPT 43775).
We decided that the Plan does not have to pre-approve the esophagogastroduodenoscopy (CPT 43235) and
excision, excessive skin and subcutaneous tissue (includes lipectomy) (CPT 15830).
You asked the Plan to pre-approve laparoscopy, surgical, gastric restrictive procedure (CPT 43775), an
esophagogastroduodenoscopy (CPT 43235) and excision, excessive skin and subcutaneous tissue (includes
lipectomy) (CPT 15830). The Plan says that based on Medicare guidelines, the bariatric surgery with multiple
procedures: 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve
gastrectomy); 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of
specimen(s) by brushing or washing, when performed (separate procedure); 15830 Excision, excessive skin and
subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy that you and/or your
provider is/are requesting does not meet the requirements for approval.
The Plan follows Medicare rules. Medicare rules say in relevant part, that effective for services performed on
and after June 27, 2012, Medicare Administrative Contractors (MACs) acting within their respective
jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment
of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions
a.-c. are satisfied. The beneficiary has a body-mass index (BMI)  35 kg/m2, the beneficiary has at least one
co-morbidity related to obesity, and the beneficiary has been previously unsuccessful with medical treatment
for obesity. Medicare rules also say that medically necessary services are those that are reasonable and
necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to
improve the functioning of a malformed body member. The rules say that services that are not medically
necessary are not covered.
We decided that the Plan has to pre-approve laparoscopy, surgical, gastric restrictive procedure
(CPT 43775).
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the laparoscopy, surgical, gastric
restrictive procedure (CPT 43775). Our reviewer says that the laparoscopy, surgical, gastric restrictive
procedure (CPT 43775) meets the Medicare coverage criteria. Our physician reviewer found that the record
indicates that the enrollee has morbid obesity with hypertension, dyslipidemia, and obstructive sleep apnea as
co-morbidities. She required weight loss to decrease the morbidity of the surgery, but she still remains
morbidly obese. The elements of the coverage criteria for laparoscopic sleeve gastrectomy are satisfied.
The procedure is recommended. Therefore, we decided that the Plan has to pre-approve the laparoscopy,
surgical, gastric restrictive procedure (CPT 43775).
We also decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (CPT 43235)
and excision, excessive skin and subcutaneous tissue (includes lipectomy) (CPT 15830).
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an esophagogastroduodenoscopy
(CPT 43235) and excision, excessive skin and subcutaneous tissue (includes lipectomy) (CPT 15830). Our
reviewer says that the record does not establish the medical necessity or reasonableness of the requested
intraoperative esophagogastroduodenoscopy because the enrollee is known to have a hiatal hernia. The record
states that the enrollee has already had a panniculectomy. A repeat panniculectomy is not medically reasonable
and necessary at this time. Therefore, we decided that the Plan does not have to pre-approve an
esophagogastroduodenoscopy (CPT 43235) and excision, excessive skin and subcutaneous tissue (includes
lipectomy) (CPT 15830).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.