Bariatric Duod Swtch denials: 73.6% overturned by independent reviewers
In 91 California IMR decisions from 2005 to 2018, reviewers overturned the plan 67 times (73.6%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Morbid Obesity | 89 | 75.3% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 27 | 85.2% | 73.6% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 10 | 10.0% | 73.6% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 100.0% | 73.6% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 73.6% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair for treatment of the enrollee’s obesity. Findings: The physician reviewer found that the request for duodenal switch procedure with hiatal hernia repair is medically necessary for treatment of the patient’s medical condition. According to the documentation submitted for review, the …”
“A 29-year-old female enrollee has requested duodenal switch procedure for treatment of her obesity. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patient’s case. The current medical evidence supports the requested duodenal switch procedure in this clinical setting. This patient has a body mass index of 44 with multiple …”
“A 46-year-old male has requested a duodenal switch procedure for treatment of his obesity. Findings: The physician reviewer found that the current medical evidence supports the requested procedure in this clinical setting. This patient meets all standard nationally accepted criteria for bariatric surgery. The requested procedure is a standard primary treatment for morbid obesity and is approved by the American …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Bariatric Duod Swtch denials overturned?
In 91 California IMR decisions from 2005 to 2018, reviewers overturned the plan 67 times (73.6%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.