Bariatric Lap Band denials: what the review data shows

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 gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair. This patient has longstanding history of morbid obesity and is status post lap band removal and conversion to sleeve. The records document that the patient has sustained complications of the sleeve procedure with worsening GERD and dysphagia which may be related to the residual gastric cardia and hiatal hernia. The patient’s pH monitoring was consistent with severe GERD. In specific clinical setting, the standard treatment for GERD secondary to sleeve gastrectomy complications is conversion to Roux-en-Y gastric bypass surgery. This patient lost pounds with the sleeve gastrectomy and remains morbidly obese.

Where the denial was upheld

A 40-year-old female enrollee requested a panniculectomy (CPT 15830) for medical treatment of her excessive skin. Findings: The physician reviewer found that overall, there is inadequate documentation to support that the patient has a functional deficit that would benefit from panniculectomy. The provider’s notes do not include sufficient detail of the abdominal overhang and the dermatologic treatment that has been attempted. The medication history does not list any topical medications that may be used to treat rashes and/or fungal infections. The photographs depict only a mild overhang and the area underneath the overlap is not provided for evaluation. The examination notes do not include any evidence of intertrigo, increased moisture, malodor and/or chronic changes to support that a functional deficit exists.

The patient is a 37-year-old female who had a body mass index (BMI) of 53 when evaluated for bariatric surgery. Her comorbid conditions included dyspnea on exertion, degenerative joint disease, fatty liver and lower extremity edema. The patient’s provider indicates her BMI had decreased to 49.5 and she has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. The psychological evaluation was absent from the record. The patient has selected the Lap Band procedure because she believes it is less invasive than other alternatives for surgical weight loss.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Bariatric Lap Bandwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.