Sleeve Gastrectomy Case Study

A review of the records reveals the member to be an adult female with a birth date of 03/01/1960. The member has a diagnosis of morbid obesity. The member’s treating provider, Noel Williams, MD recommended the member undergo a laparoscopic longitudinal sleeve gastrectomy.

The carrier has denied coverage of laparoscopic longitudinal sleeve gastrectomy as not medically necessary. There is a letter from the carrier to the member dated 11/03/2015, which states in part:

“This request has been denied as benefit exclusion because: Member does not have benefit for 2nd surgical procedure unless the proposed procedure results in technical failure or when the proposed procedure is required to treat complications of the initial procedure, which if left untreated, would result in endangering the health of the individual.”

There is a letter from Noel Williams, MD dated 10/21/2015, which states in part:

“The above captioned patient has inquired about Laproscopic Sleeve Gastrectomy procedure for morbid
Specifically, the member is 56 years old and has a body mass index of 46 kg/m2 associated with comorbid diseases of hypertension and sleep apnea. She has been cleared for the proposed bariatric operation from a mental health standpoint. A comprehensive bariatric program including nutritional and psychological components has evaluated the member. Provision of sleeve gastrectomy is consistent with the member’s condition and is consistent with standards of good medical practice. This treatment is medically proven to be effective treatment for the condition of morbid obesity, is not performed for the convenience of member or provider, and is the appropriate level of service which can be safely provided to this member. The member has a failed history of weight loss and she is seeking provision of a sanctioned bariatric operation with proven safety and