Duodenal Switch denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1This is a 55-year-old patient with a BMI of 62. The patient has tried multiple medical regimens for weight loss without success. There are also multiple comorbid factors, which include diabetes mellitus, degenerative disc disease, hypercholestremia, and hypertriglyceridemia. Based upon the information provided, it does not appear that the patient has undergone a formal psychiatric evaluation. The patient wishes to undergo a duodenal switch procedure.I have reviewed all of the supporting documents provided. In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. Techniques in duodenal switch have been available since the 1980s. With duodenal switch, patients lose weight in the range of 69% to 80%. Complications have been reported to be comparable to other operations.

Physician 1: The patient is a 62-year-old female with a body mass index (BMI) of 39. The patient has multiple comorbidities that will be ameliorated or eliminated by bariatric surgery. She requires long-term NSAIDs for osteoarthritis and has failed conventional weight loss therapy. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied coverage for the requested procedure indicating it is experimental.The duodenal switch procedure has a track record greater than 15 years. There are now long-term studies describing equal or greater weight loss with the duodenal switch procedure than with Roux-en-Y. The data reveals duodenal switch results in few incidents of dumping and anastomotic stricture.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair for treatment of the enrollee’s obesity. Findings: The physician reviewer found that based on the documentation submitted for review, the patient is an adult with morbid obesity. The patient underwent the lap vertical sleeve gastrectomy in 2005 but remains morbidly obese with a BMI of 46 kg/m2. Re-operative bariatric surgery is a potential treatment for persistent weight loss and duodenal switch procedure affords durable weight loss of any bariatric procedure. The duodenal switch procedure involves a sleeve gastrectomy and a malabsorptive intestinal bypass. The duodenal switch is performed either is a staged or stand-alone primary procedure.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair.Findings: The physician reviewer found that the request for the duodenal switch procedure is not medically necessary at this time. The completion and documentation of a thorough multidisciplinary evaluation is required. Both a psychological and dietary evaluation is clinically indicated. The patient underwent a psychological evaluation, however a dietary evaluation specifically in regards to the duodenal switch procedure and review of fat and water soluble micronutrient intake deficiency is not documented. Although the patient attended an in-Plan nutrition class, it is not documented that the effects of the duodenal switch procedure were discussed.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Duodenal Switch, then check the rights and deadlines that apply to your plan.