Received letter from secondary insurance

Dec 07, 2010

Here is what the letter from my secondary insurance says:

We fowarded your request to preauthorize coverage for a revision from a failed gastric bypass to a gastric reduction/duodenal switch procedure to correct severe complication from the previous bariatric procedure for (patient name) to the medical consultant for the (insurance company name).

The consultant reviewed the information submitted and has informend us that the proposed surgery cannot be considered medically necessay at this time stating there is no objective documentation to support the condition of a post-surgical complication related to the prior gastric bypass.

The (insurance company name) medical plan requires that bariatric surgery be reviewed for medical necessity prior to allowing benefits.  Since the consultant review stated that the clinical data submitted did not support the medical necessity of revisional bariatric surgery, we will not be able to authorize coverage for the proposed surgery.

So, I did call up the insurance company, and I asked for the actual report since the letter was so vague.  And here is the report form the consultant:

Records Received:
Predetermination request, 10/25/10
Psychological evaluation, 7/21/09, 9/24/10
Nutritional evaluation, 6/11/09, 9/11/10
Esophagogastroduodenoscopy images, 4/14/10
Polysomnogram report, 2/4/10, 3/16/10
Pelvic CT, 2/15/10
Labs, 8/17/09
Procedure report, 2/26/02, 4/9/03
Primary care provider note, 1/8/09, 5/12/09
Authorization requestes, 8/21/09, 5/5/10
Handwritten patient diet and exercise logs, 2/7/09-8/3/09
Prior review, 9/30/09
Determination request, 9/23/09
Note, 7/10/09
Consultation note, 85/12/09 (Not too sure on the "85" must be a type-o on their transcriber's part)

Summary of Treatment/Case History:
The patient is a 38 year-old woman who underwent Roux-en-Y gastric bypass in 2002.  This was performed as treatment for morbid obesity complicated by comorbid diseases of symptoms of sleep apnea, lower extremity edema, exertional dyspnea, and pain in the knees.  Prior to the 2002 bariatric procedure, the patient weighed 317 lbs (body mass index 54 kg/m2).

Following this procedure, the patient had weight loss of 166 pounds over the first post-surgical year.  Her lowest recorded weight was 151 pounds.  Gradually, the patient gained 85 pounds.  She now weighs 226 lbs (BMI 40 kg/m2).

The patient was evaluated by Dr. A. Keshishian for consideration of revisional bariatric surgery.  The listed comorbidities include dumping syndrome, solid food intolerance, abdominal pain, sleep apnea, edema, dyspnea, pain in the knees, and restless leg syndrome.  She also has gastroesophageal reflex diseas (GERD) and stress urinary incontinence.

Additional clinical data includes a pre-authorization request for revision of a failed gastric bypass to a gastric reduction/duodenal switch.  A psychological evaluation on 9/24/10 describes no mental health issues to preclude this patient from surgery.  A nutritional consultation dated 9/11/10 describes her current eating patterns.  She has received nutritional counseling and education.  A sleep study confirms sleep apnea for which a C-PAP has been prescribed.  A CT scan describes no apparent complications related to her prior gastric bypass.  There is a nutritional note dated 6/11/09 that is essentially the same as the more recent note dated 9/11/10.  There is a patient-reported daily food log from February 2009-August 2009.

The reviewer indicated that additional information would be required prior to authorizing a revision of a prior bariatric surgery.

Explanation of findings:
1.  Please review and let the client know if the proposed surgery is medically necessary in this case.

The avaliable clinical data, while voluminous, does not support the medical necessity of revisional bariatric surgery for this patient.  The pre-authorization request dated 10/25/10 states that the patient is 'seeking surgical intervention to correct severe complications from her previous bariatric procedure'.  However, the clinical data does not indicate what this severe complication is.  There is no documentation to support a specific complication of her prior gastric bypass such as anastomotic stricture, ulcer, pouch dilation, or gastro-gastric fistula that might explain her weight regain and reported abdominal pain.  Aditionally, while there is a patient-reported food log, there is no documentation to support that this patient has participated in a supervised dietary weight loss program.  There are two nutritional notes dated 6/11/09 and 9/11/09. This part is wrong, stating that there is no documentation that I participated in a supervised weight loss program.  I started in January 2009 with my PCP, ((Almost 2 years ago, and continued monthly)) and the PCP put me on phentermine as well.

It remains that the proposed revisional procedure is not medically necessary.

Conclustions/Decision to Not Certify:
This patient is 8 years status post Roux-en-Y gastric bypass.  While her initial weight loss was very good, she has been unable to sustain this and has regained 85 ponds.  There is no objective documentation such as upper endoscopy or upper GI contrast study to support the condition of a post-surgical complication as is stated by the surgeon.  The CT scan was performned in February 2010 does not describe any specific complication related to the prior gastric bypass.  The avaliable documentation does not support that the reviasional bariatric surgery as proposed by Dr. Keshishian is medically necessary for this patient.

References Used in Support of decision:
Brolin R, et al. Weight Loss Outcome of Revisional Bariatric Operations Varies According to the Primary Procedure.  Ann Surg. 248(2): 227-232, Aug 2008

Surgerman, H. Summary: Consensus Conference on Surgery for Severe Obesity.  Surgery for Obesity and Related Diseases 1 (2005) 369-370.

Sjostrom L, Narbro K, et al. Effects of Bariatric Surgery on Mortality in Swedish Subjects. N Engl J Med 357;8 2007: 741-752

Bray G. The Missing Link - Lose Weight Live Longer. N Engl J Med 357;8: 2007: 818-820.Sugerman, H. Summery: Consensus Conference on Surgery for Severe Obesity.  Surgery for obesity and Related Diseases 1 (2005) 369-370.

Ukleja A, Dumping Syndrome: Pathopsysiology and Treatment, Nutrition in Clinical Practice, Vol. 20, No. 5, 2005 517-525.

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                                                        Their standard HIPPA and release of liability

The Physician who provided this review is a Diplomat of the American Board of Surgery.  The reviewer is a fellow of the American College of  Surgeons and the International College of Surgeons.  The reviewer has completed a fellowship in laparoscopic procedures.  This reviewer is a member of the American Society of Bariatric Surgeons.  This reviewer has been in active practice since 1998.

It is the ploicy of the Medical Review Institute of America to keep the names of its reviewing physicians confidential.  Accordingly, the identity of the reviewing physician will only be released as required by state or federal regulations.  If released of the review to a third party, including insured and/or provider, is necessary, all applicable state and federal regulations must be folloed.

The written opinions provided by MRIoA represent the opinions of the physician reviewers and clinical advisors who reviewed the case.  These case review opinions are provided in good faith, based on the medical records and information submitted to MRIoA for review, the published scientific medical literature, and other relevant information such as that avaliable through federal agencies, institutes and professioanl associations.  Medical Review Institute of America assumes no liability for the opinions of its contracted physicians and/or clinican advisors.  The health plan, organization or other party authorizing this case review agrees to hold MRIoA harmless for any and all claims which may arise as a result of this case review.  The health plan, organization or other third party requesting or authorizing this review is responsible for policy interpretation and for the final determination made regarding coverage and/or eligibility for this case.

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