Gastric Bypass With Duodenal Switch denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 36-year-old female with a body mass index (BMI) of 42.7. In addition the patient has a history of gastroesophageal reflux disease, hiatal hernia and paraesophageal hernia. She is status post laparoscopic Nissen fundoplication and cholecystectomy. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied this request indicating the requested procedure is considered investigational for treatment of the patient’s morbid obesity.The patient has a documented 20-year history of obesity refractory to conservative diet therapy and presently has symptoms of chest pain, shortness of breath, GERD, and edema directly related to her obesity.

The patient is a 57-year-old female with recurrent ventral hernia who has failed vertical banded gastroplasty. The patient’s body mass index (BMI) is 50. The submitted information indicates there was previous use of Marlex mesh for the patient’s hernia repair. The patient’s providers have recommended gastric bypass surgery with duodenal switch. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational.There is now adequate data to demonstrate that duodenal switch is a more appropriate weight loss procedure for certain surgical revisions. Salvage from failed vertical banded gastroplasty involves conversion to Roux-en-Y gastric bypass or duodenal switch gastric bypass. In many cases, dense upper abdominal adhesions make conversion to Roux-en-Y gastric bypass untenable.

Where the denial was upheld

The patient is a 62-year-old male with a body mass index of 50. He has significant obesity related comorbidities. The patient is estimated to be a high operative risk (5%). The patient wishes to undergo gastric bypass with duodenal switch. The Health Plan has determined that the requested procedure is not medically indicated for treatment of the patient’s medical condition.With a body mass index (BMI) of 50 and significant comorbid conditions, the patient appears to be an appropriate candidate for weight loss surgery. Given the patient’s BMI and comorbidities duodenal switch would be the preferred weight loss procedure. However, given the significance of his comorbidities he is a high operative risk. As such, updated cardiac and nephrology evaluations are necessary to determine if surgery is a viable option for this patient.

A 36-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollee’s morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.

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 Gastric Bypass With Duodenal Switch, then check the rights and deadlines that apply to your plan.