Post Surg Complicat: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lap-band removal and gastric bypass surgery for treatment of the enrollee, who is status post Lap-band placement. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The Lap-band is a mechanical device which has a high explant rate secondary to complications related to the device, failure of the device to result in intended weight loss and/or intolerance to the device. This patient has worsening gastroesophageal reflux disease. Per the medical records, she requires Lap-band removal to prevent secondary complications of prolapse, erosion and slippage. Therefore, the requested Lap-band removal is medically necessary for the treatment of this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision gastric bypass with lap band removal for sleeve gastrectomy for treatment of her complications related to lap band surgery. Findings: The physician reviewer found that based on the documentation submitted for review, the request for lap band removal is medically necessary. This patient has negative symptoms related to the lap band. Although there are no anatomic complications noted, intolerance is a medically necessary indication for lap band removal as it is associated with increased risk of secondary complications such as prolapse, obstruction, erosion. However, the request for conversion to sleeve gastrectomy is not medically necessary for this patient. The U.S.

Where the denial was upheld

The patient is a 41-year-old female who is 5’6” weighing 304 pounds with a body mass index (BMI) of 48. The patient underwent Lap-Band surgery in 1998. At the time of surgery the patient weighed over 500 pounds. Her weight reportedly dropped to 180 pounds following the procedure. She has been experiencing weight gain and worsening of distal esophageal dilation. The patient is status post multiple Lap-Band adjustments. She wishes to undergo revisional gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically indicated for treatment of the patient’s medical condition.Review of the medical literature indicates revisional weight loss surgeries have a high complication rate.

The patient is a 33-year-old female who is status post laparoscopic Roux-en-Y gastric bypass in 2001 with significant weight loss (207 pounds). She has since had weight regain and several bowel obstructions requiring laparoscopic lysis of adhesions and reduction of internal hernias. Her provider’s request for authorization of a revisional duodenal switch procedure was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The biliopancreatic diversion with duodenal switch is not an investigational procedure. However, the surgical conversion from a Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch is a technically demanding procedure as it requires complete take down of the Roux-en-Y gastric bypass, jejunojejunostomy, gastrogastrostomy, sleeve gastrectomy and small bowel reconstruction.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for post surg complicat was denied, the published record says the denial is worth fighting.