Diagnosis: Obesity
Treatment: Bariatric Surgery The plan denied bariatric surgery
The health plan's determination is upheld.

This patient has weight related co-morbid conditions include: sleep apnea, hypertension (HTN), and diabetes mellitus (DM). The patient is status/post (s/p) lap band procedure in 2012. An esophagogastroduodenoscopy (EGD) revealed no erosion, gastroesophageal reflux disease (GERD) and gastritis. Additional information, updated dietary and psychological status specifically in regards to gastric bypass, was requested. Additional information was provided and reviewed including a dietary evaluation . A psychological evaluation was not provided. At issue is the medical necessity of bariatric surgery.

The bariatric surgery is not medically necessary based on the information provided. A dietary evaluation was obtained that did not reveal any obvious barriers to surgery. Reoperative bariatric surgery warrants an updated psychological evaluation specifically in regards to the type of surgery and whether the patient is a reasonable candidate, which was not provided for review.

Although this patient is super obese and may benefit from bariatric surgery, medical necessity cannot be determined without an updated psychological evaluation specifically for possible reoperative intervention with conversion to gastric bypass.

The American Society for Metabolic & Bariatric Surgery [ASMBS] (perioperative care) guidelines and the National Institutes of Health (NIH) consensus guidelines and the ASMBS reoperative guidelines recommend that patients who are being considered for treatment of morbid obesity undergo a behavioral/psychological evaluation to ensure that the patient is an appropriate candidate for primary to reoperative bariatric surgery. Gastric bypass has unique risks, such as dumping, changes in ethyl alcohol (ETOH) pharmacokinetics, reactive hypoglycemia and risks from smoking/medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).