Sleeve Gastrectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sleeve gastrectomy. According to the American Society for Metabolic and Bariatric Surgery, qualifications for bariatric surgery in most areas include a BMI greater or equal to 40, or more than 100 pounds overweight; a BMI greater or equal to 35, with at least one or more obesity-related co-morbidities such as type II diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease; or an inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.In this case, the patient meets all nationally accepted criteria for bariatric surgery, including those published by the American Society for Metabolic and Bariatric Surgery.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery (CPT code 43775-laparscopy, surgical gastric restrictive procedure, longitudinal gastrectomy (i.e. sleeve gastrectomy)) with two day stay for treatment of the enrollee's morbid obesity and hip pain. Findings: The physician reviewer found that there is support in the medical literature as well as in the documentation provided for review to support the requested services in this clinical setting. Based on the records, this patient meets the criteria for bariatric surgery from the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. The patient is morbidly obese. The patient has failed dietary efforts without success and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sleeve gastrectomy for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has a history of morbid obesity and underwent Lap-band surgery. This needed to be emergently removed secondary to complication of slipped band. The Lap-band, unlike other metabolic bariatric procedures is a foreign body and when removed no longer leaves any permanent tool for weight loss. Therefore, the natural history is that these patients may ultimately regain weight without a more durable metabolic bariatric procedure. In this patient’s case, her body mass index is slightly under 35, and she has hypertension.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sleeve gastrectomy. On review of the current guidelines from the American Society of Metabolic and Bariatric Surgery (ASMBS), this patient does not meet the criteria for the requested sleeve gastrectomy. Specifically, the patient’s records do not document a history of type 2 diabetes mellitus or other obesity-related comorbidities. In addition, the ASMBS guidelines require patients to undergo nutritional and psychiatric counseling as part of a multidisciplinary clinic evaluation prior to bariatric surgery, which is not documented in this patient’s chart. Moreover, the provider did not report that the patient has tried and failed treatment with a glucagon-like peptide-1 (GLP1) agonist prior to consideration for bariatric surgery.

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 Sleeve Gastrectomy, then check the rights and deadlines that apply to your plan.