Court Finds Gastric-Bypass Surgery is Medically Necessary

July 20, 2004 ( - A medical plan participant's request for gastric-bypass surgery was found to be "medically necessary," and thus should be covered under the provisions of the plan.

Awarding summary judgment to the plaintiff, the US District Court for the District of Maine found an Employee Retirement Income Security Act (ERISA) governed medical plan’s administrator made an unreasonable denial of benefits under the arbitrary and capricious standard of review.   Rather than consider such an operation to be excluded from plan coverage, the court said gastric-bypass surgery should be considered “medically necessary.”

“The question presented thus is whether the Defendants’ interpretation of the Plan to exclude such coverage is ‘reasonable,'” US Magistrate Judge David Cohen said in the opinion, finding, “the contemplated gastric-bypass surgery clearly meets the Plan’s definition of a ‘Covered Expense.'”

Tanya Lowell, who suffered from morbid obesity, submitted a pre-procedure determination claim for gastric-bypass surgery to determine of theDrummond, Woodsum & MacMahon Employee Medical Plan, which Lowell participated in, would pay for the operation.   In December 2001 Machigonne, the plan’s administrator, informed Lowell that her request for reauthorization was denied on the ground that the surgery was not medically necessary.

Machigonne made this determination based on the plan’s “General Exclusions.”   Specifically, Machigonne relied on Exclusion 11, which states, “Benefits will not be provided for any service that is not medically necessary and appropriate, including … “[a]ny expense for weight reduction, nutritional or dietary counseling.”

Lowell requested coverage for gastric-bypass surgery again in 2003.   The plan again denied her claim, finding the procedure was not covered under the provisions of Exclusion 11.

Following the second denial, Lowell filed suit in federal court.   In her suit, Lowell claimed the denial of gastric-bypass surgery was in violation of Section 502(a) of ERISA.

Initially, Lowell’s case hit a bump in the road, whenthe court ruled that Lowell could not expand the administrative record in her case to determine how the plan administrator had in the past interpreted Exclusion 11 to exclude coverage for weight reduction treatments.   Despite this initial setback, ultimately t he district court finds “although Lowell loses this battle, she wins the war” in awarding Lowell summary judgment.   

Ultimately, the court found the plan “presented no evidence disputing the medical necessity of Lowell’s gastric-bypass surgery,” rather, the plan clashed with Lowell over “whether the Plan does or does not cover such an expenditure.”   In this case, such a procedure would be covered since the court found the record showed the surgery was not for weight reduction per se, but “to reduce or eliminate associated morbidities.”

The case is Lowell v. Drummond, Woodsum & MacMahon Employee Medical Plan , District of Maine, No. 03-244-P-S.