Diagnosis: Obesity
Treatment: Weight reduction surgery (procedure code 43775) and inpatient stay
The insurer denied coverage for weight reduction surgery (procedure code 43775) and inpatient stay.
The denial is upheld.

This female patient has a history of anxiety, depression, fibromyalgia, Hashimoto's disease, hypothyroidism, migraines, peptic ulcer disease, and obesity.

The insurer has denied coverage for weight reduction surgery (procedure code 43775) and inpatient stay (date of service to be determined) as not medically necessary. They stated in a final adverse determination letter that the records tell us that the ratio of your height and weight (BMI) is less than 40. The patient also has sleep apnea. Medical studies have shown that weight loss surgery improves patient outcomes in patients with a BMI of 35-40 if they also have (life threatening) medical problems (complications of obesity). Those medical problems can include high blood pressure, diabetes, and severe sleep apnea (AHI [apnea-hypopnea index] scores over 30). Because weight loss surgery for patients with a BMI of 35-40 and no (life threatening) medical problems has not been proven to improve your health, it is not medically necessary for you. Because they cannot approve the operation, they cannot approve a hospital admission. They based this decision on the health plan clinical guidelines (CG), Surgery for clinically severe obesity (CG-Surg-83).

This patient has a BMI of 37 approximately and does not have obesity hypoventilation syndrome as she has only mild obstructive sleep apnea (OSA) with an AHI of 6.6 and oxygen (O2) saturation of 88%. There is also no evidence that the patient demonstrated reliable participation in preoperative multidisciplinary behavior modification program (for example, preparation for postoperative diet and exercise regimens). Thus, the patient does not meet MCG (Milliman Care Guidelines) criteria.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the weight reduction surgery (procedure code 43775) and inpatient stay is upheld. The medical necessity is not substantiated.