Diagnosis: Obesity
Treatment: Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy
The insurer denied Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy. The health plan's determination is overturned.

The patient is a woman who has medically complicated morbid obesity. Her weight was 250 lbs. She is 66 inches tall. This corresponds to a body mass index (BMI) of 40.4. The records indicate that the patient has been significantly overweight for many years. She has attempted weight loss with conventional diet programs. The patient has comorbid health conditions of high cholesterol, sleep apnea treated with continuous positive airway pressure (CPAP), and hypertension.

Gastric Restrictive Procedure, Sleeve Gastrectomy by Laparoscopy is medically necessary for this patient. The current standard of care for successful candidacy for bariatric surgery such as laparoscopic sleeve gastrectomy are: BMI of 40 or a BMI of 35 in association with weight related comorbid illnesses such as hypertension, diabetes, sleep apnea, osteoarthritis, etc. There must also be documentation of prior nonsurgical attempts at weight loss, nutritional counseling/education, mental health clearance for the proposed surgery, and commitment for long term follow up post bariatric surgery.
In this case, the patient has a body mass index of 40.4 with comorbid, weight related conditions of high cholesterol, sleep apnea, and hypertension. She has successfully completed a comprehensive multidisciplinary evaluation that includes surgical, medical, psychological and nutritional components. The proposed bariatric operation is medically necessary for this patient and is consistent with nationally recognized standards.