Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the removal of an adjustable gastric restrictive device and 
subcutaneous port components. We decided that the Plan does not have to pre-approve gastric bypass with 
Roux-en-Y gastroenterostomy.  
 
You asked the Plan to pre-approve the removal of an adjustable gastric restrictive device and subcutaneous port 
components (43774) and gastric bypass with Roux-en-Y gastroenterostomy (43644). You say that you are 
having issues keeping food down. You say that the records provided support that the requested procedures are 
medically necessary. The Plan says that the records do not show that the enrollee has a body mass index of 
greater than 35. 
 
We decided that the Plan has to pre-approve the removal of an adjustable gastric restrictive device and 
subcutaneous port components.  
 
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or 
service, then that item or service will be covered when it is medically necessary.  
 
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 removal of an adjustable gastric 
restrictive device and subcutaneous port components. Our reviewer says that the criteria for coverage have 
been met. Our physician reviewer found the enrollee has a history of morbid obesity with an initial weight of 
350 pounds. Our physician reviewer found that the enrollee underwent a lap band procedure in 2008. Our 
physician reviewer found that the enrollee has had ongoing issues with dysphagia and GERD and per os (PO) 
intolerance. Removal of the lap band and port for complications of GERD is considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the removal of an adjustable gastric restrictive device and subcutaneous port 
components have been met. Therefore, we decided that the Plan has to pre-approve the removal of an 
adjustable gastric restrictive device and subcutaneous port components.  
 
We also decided that the Plan does not have to pre-approve gastric bypass with Roux-en-Y 
gastroenterostomy. 
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic Roux-en-Y gastric bypass (RYGBP) are 
covered for Medicare beneficiaries who have a body-mass index of 35 or more.  
 
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 gastric bypass with Roux-en-Y 
gastroenterostomy. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found that the enrollee does not have a body-mass index of 35 or more.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastric bypass with Roux-en-Y gastroenterostomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve gastric bypass with Roux-en-Y 
gastroenterostomy. 
 
 
 
 
 
 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.