Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient had a gastric sleeve procedure performed on or about 2014 at a weight of 236 pounds. The submitted documentation reflects that the patient initially lost weight following the sleeve procedure but regained a portion during a pregnancy that followed. Records indicate that the patient had a cesarean section performed in 2016. More recent medical records reflect that an upper gastrointestinal series performed on 1/24/18 showed that the patient had reflux to the mid thoracic esophagus. A progress note dated 2/28/18 indicates the patients weight to be 197 pounds, with a body mass index (BMI) of 30.8. More recent progress notes show that the patient gained weight over the next several months, from 220 pounds on 3/28/18 to 228 pounds on 6/27/18, with a BMI of 35.7. Progress notes indicate that the patient has significant co-morbidities that are related to her weight, including, but not limited to, sleep apnea and Gastroesophageal Reflux Disease (GERD). Records indicate that the patients sleep apnea is being treated with CPAP therapy and that her GERD is being treated with medications. At this time, the patient has requested authorization and coverage for revision bariatric surgery from a gastric sleeve to the laparoscopic gastric band. The submitted documentation reflects that a more accurate technical description for the requested procedure would be the placement of an adjustable gastric band over a sleeve gastrectomy, since the patients sleeve would remain intact. This is not technically a `revision`, but rather a conversion from a sleeve to a `band over sleeve`. Records reflect that the patient has undergone nutritional and behavioral health evaluations, as appropriate.At issue in this case is whether the revision bariatric gastric surgery from gastric sleeve to a laparoscopic gastric band is medically necessary for the patients medical condition. The submitted documentation does not support that the requested procedure is medically necessary. Placing a band over an existing sleeve gastrectomy is not an acceptable procedure by the American Society for Metabolic and Bariatric Surgery (ASMBS) at this time. There are no articles on the subject and only one recent poster documenting five patients. In a recent review of banded sleeve gastrectomy as a primary operation, there are only 238 patients in the published literature who have had this procedure as a primary procedure. In addition, GERD is the major reason that laparoscopic bands can fail. The placement of a constricting band, below the area of reflux, is seen as a contraindication. Changes in esophageal function following the band procedure tend to augment the GERD symptoms. In this case, the patient has a known diagnosis of GERD and has documented reflux to the mid-thoracic esophagus, which is a contraindication for a band procedure. Under these circumstances, the requested revision bariatric gastric surgery from gastric sleeve to a laparoscopic gastric band is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.