Diagnosis: Morbid obesity

Treatment: Procedural code 43845 duodenal switch

The insurer denied coverage for procedural code 43845 duodenal switch.

The denial is overturned.

The patient has morbid obesity and gastroesophageal reflux disease (GERD). A lap band was placed. She lost 70 pounds but then the lap band became less effective. She gained weight and had a body mass index (BMI) of 48.9. The physician is now advising lap band removal and a duodenal switch.

UpToDate article titled "Bariatric procedures for the management of severe obesity" discusses revisional procedures. There is a laparoscopic approach to a failed bypass with biliopancreatic diversion and duodenal switch. UpToDate gives a reference to an article from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The guideline states that the Laparoscopic Duodenal Switch is a superior operation which preserves the antro-pyloric pump and leaves the vagal innervation undisturbed. A recent comparison of biliary pancreatic diversion and duodenal switch after 10 years of follow-up demonstrated the superiority of duodenal switch with better weight loss and lesser revisions.

The scientific literature supports the use of the duodenal switch when a lap band has failed. It is advised by the Society of American Gastrointestinal and Endoscopic Surgeons. The patient is a good candidate because she has a failed lap band and has massive obesity. There are several options for patients with failed lap bands, but this procedure has been shown to be effective. It is likely to be more beneficial because it has been shown to produce superior weight loss as compared to other procedures. The risks are similar to any surgical procedure.

The carrier's denial of a surgical procedure on the stomach, procedure code 43845, should be overturned.