Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 57-year-old female who had a body mass index (BMI) of 37. In addition, she had multiple comorbidities. Her cholesterol/HDL ratio was in the normal range. She was on single drug treatment for hypertension. The patient was less than 100 pounds over ideal body weight. The patient underwent Lap-Band surgery in September 2004. The Health Plan has denied coverage for the Lap-Band on the basis it is considered investigational.With a BMI of 37 and no severe comorbidities, the patient did not meet nationally accepted medical necessity criteria for weight loss surgery. Her BMI was less than 40 and her comorbidities did not rise to the level to justify operative intervention of any type. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 57-year-old female who was 51 weighing 190 pounds with a BMI of 37 and also had hypertension and hypercholestemia. She underwent the Lap-Band procedure on 9/12/04. She is requesting reimbursement for the procedure. The Health Plan has denied this request indicating the procedure at issue is considered experimental.Given the patients BMI and lack of any significant comorbidities, she did not meet nationally accepted criteria for weight loss surgery. There was potential that further attempts at conservative weight loss would have been successful. Furthermore, as the patient had the potential for further weight loss through conservative means, the risks of weight loss surgery outweighed the potential benefits of the procedure. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 57-year-old female patient who had a BMI of 37.1. Her risk factors included hypertension, hypercholesterolemia and degenerative joint disease. She had attempted multiple weight loss programs without success. She underwent Lap-Band surgery in September 2004 and is seeking reimbursement. The Health Plan has determined the Lap-Band is considered experimental.Though the patient had a BMI of less than 40, her comorbidities were severe enough to warrant weight loss surgery. Lap-Band surgery was approved by the FDA in 2001. Up to 80,000 worldwide have undergone the Lap-Band procedure. The morbidity of the Lap-Band is reported as lower than the Roux-en-Y gastric bypass. The Lap-Band can be adjusted at different times after the initial procedure to provide different levels of restriction. A recent study (see citations above) following 625 patients for three years showed acceptable morbidity and positive results. Excess weight loss was seen in 49.9% of patients after the second year. Overall, it appears this procedure provides greater benefit than Roux-en-Y gastric bypass. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.