Roux-en-y Gastric Bypass denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for weight loss surgery involving CPT code 43644 (laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm of less), CPT code 43846 (Gastric restrictive procedure, with gastric bypass, for morbid obesity, with short limb (less than 100 cm) Roux-en-Y gastroenterostomy and two days of inpatient acute hospitalization. The health plan has denied this request as not medically necessary. A review of the records indicates this enrollee was evaluated by her surgeon for gastric bypass weight loss surgery. She previously weighed 215 pounds but had reduced her weight to 193 pounds using a professionally monitored weight loss program with exercise.

The patient is a 36-year-old female with a body mass index (BMI) of 40 and comorbid conditions including urinary stress incontinence, gastroesophageal reflux disease, and depression. In addition, it has been noted that the patient has a history of migraine headaches. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied authorization and coverage for gastric bypass on the basis that it is not medically necessary.With a BMI of 40 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patient’s morbid obesity.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for Roux-en-Y gastric bypass procedure. The enrollee has diagnoses of systemic lupus erythematosus (SLE), morbid obesity, obstructive sleep apnea, hypertension, and asthma. Findings:She was evaluated for bariatric surgery due to her body mass index (BMI) of 43. She underwent a gastric sleeve procedure. Her weight at that time was 277 lbs. A follow-up visit demonstrated a 79-lb. weight loss. She reported attempts to adhere to dietary and exercise routines, but other physical maladies had limited her exercise abilities and her weight had increased to 230.5 lbs.

The patient is a 46-year-old female who is 5’1” weighing 240 pounds with a body mass index (BMI) of 45. She has comorbid conditions of hypertension, asthma, and osteoarthritis. She is status post Nissen fundoplication. She has been approved for bariatric surgery on the condition that she loses weight preoperatively and attends support group meetings. She has not complied with these conditions. Based upon the information provided, she has not been evaluated by a bariatric surgeon since 2004. In addition, it is unclear when the patient underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions the patient meets accepted criteria for consideration of weight loss surgery.

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 Roux-en-y Gastric Bypasswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.