Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Surgical procedure on the stomach (bariatric surgery).
The insurer denied surgical procedure on the stomach (bariatric surgery).
The determination is overturned in part.

This patient is under consideration for bariatric surgery. She was 62 inches tall and weighed 270 pounds (lbs). This corresponds to a body mass index (BMI) of 49.4 kilograms per square meter (kg/m2). She has comorbid health conditions of joint disease, hypertension, and sleep apnea for which continuous positive airway pressure (CPAP) has been prescribed. The patient has attempted weight loss with conventional weight loss programs as detailed in the surgical assessment. However, she has not been successful with significant sustained weight loss.

The patient sought evaluation for bariatric surgical consultation. The records indicate that she was entered into a multidisciplinary bariatric program. Psychological evaluation provides mental health clearance. The patient received nutritional counseling and education. The patient consulted with a nutritionist. Her thyroid stimulating hormone (TSH) was normal. Following this evaluation and because of persistent medically complicated obesity, the patient was deemed a suitable candidate for bariatric surgery (sleeve gastrectomy and concomitant pyloroplasty).

At issue is the medical necessity of surgical procedures on the stomach (bariatric surgery).

Yes, in part. Given this patient's diagnosis, her current health condition, and generally accepted guidelines for patient selection, the proposed sleeve gastrectomy is medically necessary for this patient. However, the records and existing published literature and guidelines do not support the medical necessity of the proposed pyloroplasty (CPT 43659).

This female patient  has a BM (Body Max Index)I over 40 kg/m2 with weight-related comorbid health conditions that include joint disease, hypertension, and sleep apnea for which continuous positive airway pressure has been prescribed. These are weight-related health conditions that will respond favorably to the sustained weight loss associated with sleeve gastrectomy. She has completed a multidisciplinary bariatric evaluation. She has had appropriate nutritional counseling and has been cleared for bariatric surgery from a mental health standpoint per the updated assessment. She has participated in a supervised weight loss program.

Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient per widely accepted guidelines as her BMI is over 40 kg/m2 in association with weight-related illnesses. There is serial documentation of active participation in a nonsurgical weight reduction regimen throughout the 9-months. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical evaluation with lab data and medical assessment and is felt to be an acceptable candidate. Finally, the treatment plan includes pre and post-op dietary/nutritional counseling.

From the available data. it can be expected that laparoscopic sleeve gastrectomy would be health benefits for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed bariatric operation. Accepted guidelines do not mandate that a patient have a comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy. This patient's condition warrants treatment as is proposed and this treatment would be expected to be health beneficial for her and is consistent with nationally accepted guidelines of care. However, pyloroplasty as is proposed to decrease the intraluminal gastric pressure and lessen leak risk is not a generally accepted procedure and is not supported by current guidelines. The literature submitted with the review material pertains to pyloroplasty in association with esophagectomy. The current body of literature does not include peer-reviewed data to support pyloroplasty in the setting of sleeve gastrectomy.