Diagnosis: Morbid obesity.

Treatment: Laparoscopic sleeve gastrectomy (code 43775).

The insurer denied coverage for the laparoscopic sleeve gastrectomy (code 43775).

The denial is upheld.

This is a male patient with a history of morbid obesity and seizure disorder. He had a laparoscopic (lap) band placed with an initial weight of 308 pounds. His nadir was 212 pounds. The patient suffers from dysphagia, sticking and pouch dilation requiring deflation of his lap band. His lap band cannot be deflated to the optimal point of hunger suppression and therefore lap band removal and conversion to sleeve gastrectomy is recommended by the treating provider. The patient has undergone surgical evaluation, as well as nutrition and exercise counseling, and psychological testing.

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does not meet the medical criteria and indications for bariatric surgery for sleeve gastrectomy. At the most recent visit the patient had a body mass index (BMI) of 35.9 and does not have sleep apnea/obstructive sleep apnea (OSA), diabetes, hypertension or any other co morbidity that would justify bariatric surgery. He has undergone appropriate evaluation including psych, nutrition, and followed a medically supervised program. However, he does not meet the criteria for revision surgery from a lap band to sleeve as he does not have any of the complications that would necessitate revision surgery, or the BMI with co-morbidities to justify a procedure. He does not have obstruction or severe reflux, or severe pouch dilation.

The denial is upheld at this time and coverage should not be provided for lap band removal and revision using sleeve gastrectomy in this patient. Lap band removal and revision to sleeve is standard of care when complications from the lap band have arisen.

The health care plan did act reasonably and with sound medical judgment as the patient did not meet guidelines for bariatric surgery based upon his BMI and lack of co-morbidities.

The insurer's denial of coverage for the laparoscopic sleeve gastrectomy (code 43775) is upheld. The medical necessity is not substantiated.