Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional - Obesity
Treatment: bariatric surgery and hernia repair.
The health plan denied bariatric surgery and hernia repair as not medically necessary. The health plan's determination is overturned in part. 

The patient is a male under consideration for revisional bariatric surgery. He underwent the sleeve gastrectomy procedure previously. His weight prior to sleeve gastrectomy was 280-290 pounds (lbs.). His post-surgical weight nadir was 225 lbs.
The patient consulted for the condition of weight gain and gastroesophageal reflux disease (GERD). At this time, he was 69 inches tall and weighed 335 lbs. This corresponds to a body mass index (BMI) of 49.5. The patient has obesity-related comorbid diseases of GERD and sleep apnea. His listed medications do not include any antacid medications per the progress note. The patient completed pulmonary and cardiology evaluations and was cleared for the proposed revisional operation.
He had consulted with a dietician. Upper endoscopy was performed on that showed mild esophagitis and a 1.5-centimeter (cm) hiatal hernia, in addition to anatomic changes of gastric sleeve. A contrast upper gastrointestinal (UGI) study showed anatomic changes of sleeve gastrectomy and no mention of hiatal hernia. Esophageal motility was normal, and no reflux was described during the study. A mental health evaluation was performed with clearance for the proposed revisional operation.
The doctor proposed conversion of the sleeve gastrectomy to roux en Y gastric bypass (RYGB) as a tool to augment weight loss and treat comorbid health conditions. Repair of a paraoesophageal hiatal hernia was also proposed.
The plan denial letter states that criteria for weight loss surgery include: age over 18 years, an approved type of surgery planned (includes biliopancreatic diversion with duodenal switch[BPD/DS]), BMI of at least 40, non-surgical efforts at weight loss have failed, there is mental health and medical clearance, the patient is educated as to the risks and benefits of surgery and what to expect with surgery. Criteria for concomitant paraoesophageal hernia repair include approval of the weight loss operation, this type of hernia is found during the weight loss procedure.
At issue is the medical necessity of the requested health service/treatment of bariatric surgery (Biliopancreatic Diversion with Duodenal Switch) and paraoesophageal hernia repair.
The health plan's determination of medical necessity is overturned in part.
The requested health service/treatment of bariatric surgery (Biliopancreatic Diversion with Duodenal Switch) is medically necessary for this patient. Given this patient's diagnosis, his current health condition, and medical standards in the field of bariatric and metabolic surgery, the proposed revision of sleeve gastrectomy to BPD/DS is medically necessary for this patient. 
Revisional surgery as is proposed in this case is a reasonable clinical consideration for this patient. This patient underwent sleeve gastrectomy. While he initially lost weight following surgery, he regained weight as is sometimes experienced with restrictive bariatric operations. He has weight related comorbid health conditions that will respond favorably to both weight loss and anatomic changes of BPD/DS. He has actively participated in a post-surgical program and has completed the prerequisite evaluation with mental health and nutritional consultations.
However, repair of hiatal hernia is not medically necessary as the diagnosis of paraoesophageal hernia is not definitively established based on the UGI report that does not describe such a hernia that requires operative repair.