Bariatric Duod Swtch for Morbid Obesity: 75.3% of denials overturned
In 89 California IMR decisions from 2005 to 2018, reviewers overturned 67 (75.3%). 88 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 26 | 88.5% | 75.3% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 9 | 11.1% | 75.3% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 6 | 100.0% | 75.3% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 75.3% |
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 …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair.Findings: The physician reviewer found that the request for the duodenal switch procedure is not medically necessary at this time. The completion and documentation of a thorough multidisciplinary evaluation is required. Both a psychological and dietary evaluation is clinically indicated. The …”
- 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 for Morbid Obesity overturned?
In 89 California IMR decisions from 2005 to 2018, reviewers overturned 67 (75.3%). 88 were medical-necessity disputes, 1 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
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 they weigh the same things.
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.