Bariatric Lap Band for Digestive System/ GI: 40.0% of denials overturned
In 5 California IMR decisions from 2006 to 2018, reviewers overturned 2 (40.0%). 5 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair. This patient has longstanding history of morbid obesity and is status post lap band removal and conversion to sleeve. The records document that the patient has sustained complications of the sleeve procedure with worsening GERD and …”
“A 47-year-old female enrollee has requested lap band surgery (laparoscopic banding) for treatment of her obesity. Findings: The physician reviewer found the submitted documentation establishes the medical necessity of the requested lap band surgery (laparoscopic banding). The patient meets the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of …”
And one the reviewer upheld
“A 46-year-old female enrollee has requested laparoscopic Lap-Band surgery for treatment of her obesity. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patient’s case. Although this patient is obese, severe obesity or morbid obesity is not documented. Low body mass index bariatric surgery guidelines are not fully …”
- 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 Lap Band denials for Digestive System/ GI overturned?
In 5 California IMR decisions from 2006 to 2018, reviewers overturned 2 (40.0%). 5 were medical-necessity disputes.
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.