This patient is 5 feet 7 inches tall, weighs 245 pounds giving a body mass index of 38.4 kg/m2. Weight related co-morbid conditions include: gastroesophageal reflux disease (GERD), sleep apnea. The patient is status/post (s/p) sleeve gastrectomy in 2016. An esophagogastroduodenoscopy (EGD) preformed in late 2018 showed significant dilation of the sleeve, without angulation or hiatal hernia. The patient (Pt) has symptoms despite twice daily (bid) zantac use, switched to bid proton pump inhibitor (PPI) use. Updated dietary and psychological clearance were obtained that did not reveal any obvious barriers to surgery.

The health plan's determination is overturned. The Weight Loss (Bariatric) Surgery with Associated One (1) Day Inpatient Hospital Admission is medically necessary for this patient. This patient has post sleeve gastrectomy GERD a known complication of the procedure. The patient is symptomatic despite medical management. Standard anti-reflux procedures (LINX, laparoscopic Nissen fundoplication) cannot be performed after sleeve gastrectomy since the fundus is removed and the best treatment option is conversion to Roux-en-Y gastric bypass (RYGBP). This procedure is not for weight loss, as any durable significant weight loss after conversion from sleeve to GBP is generally not reported in published studies, but for treatment of GERD in which it is generally curative.