Lap Band Procedure denials: what the review data shows

Where the denial was overturned

The patient is a 64-year-old female with a body mass index (BMI) of 49.1. She has significant clinical comorbidities. The patient has failed monitored weight loss programs. She is a candidate for bariatric surgery and wishes to undergo a Lap-Band procedure. There is no evidence in the submitted documentation the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for the proposed Lap-Band procedure.Review of the relevant medical literature demonstrates there is sufficient evidence to support the use of the Lap-Band procedure for weight loss. The Lap-Band was approved by the Food and Drug Administration in 2001. Morbidity seems to be lower with the Lap-Band procedure than with traditional vertical banding gastroplasty and Roux-en-Y gastric bypass.

A 51-year-old female enrollee has requested bariatric surgery, specifically, a Lap Band procedure for treatment of her obesity. Findings: The physician reviewer found that review of the submitted documentation demonstrates that this patient meets the generally accepted criteria for bariatric surgery, including those criteria listed by the National Institutes of Health (NIH) Consensus Guidelines. The patient has clinically severe obesity with a BMI of greater than 38 and hypertension being treated with medication. She has failed supervised dietary efforts and has completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers to surgery. Medical clearance is documented for the requested procedure and there is no documented evidence of any treatable metabolic causes of obesity in this patient.

Where the denial was upheld

The patient is a 63-year-old female with a body mass index (BMI) of 42 and significant comorbid conditions. Additionally, she has a large hiatal hernia and previous Nissan fundoplication. The record indicates the patient completed a bariatric surgery evaluation approximately three years ago and for various reasons did not proceed with surgical weight loss. At this time, the patient is requesting authorization for the Lap Band procedure. The Health Plan has denied coverage based upon their determination that the procedure it is not medically necessary for treatment of the patient’s morbid obesity.With the completion of a current, favorable psychological evaluation the patient would generally satisfy the nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the Lap Band procedure is contraindicated.

The patient is a 55-year-old female who had a weight of 282 pounds and a body mass index (BMI) of 45.5 when evaluated for bariatric surgery. Her comorbid conditions include asthma and sleep apnea. She has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patient has selected the Lap Band procedure as her treatment of choice for surgical weight loss. The Health Plan denied authorization and coverage for the Lap-Band procedure citing a lack of medical necessity.With a BMI of approximately 45.5 and comorbid conditions such as asthma and sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the current scientific data shows that the Lap-Band is inferior to other surgical alternatives in terms of excess body 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 Lap Band Procedurewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.