Bariatric Lap Band for Morbid Obesity: 45.5% of denials overturned
In 112 California IMR decisions from 2005 to 2017, reviewers overturned 51 (45.5%). 104 were medical-necessity disputes, 8 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 | 53.8% | 45.5% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 16 | 12.5% | 45.5% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 11 | 45.5% | 45.5% |
| Alternatives contraindicatedThe findings mention a contraindication to the plan's preferred option. | 5 | 60.0% | 45.5% |
| FDA approval or off-label use discussedThe findings discuss the FDA label status of the treatment. | 3 | 66.7% | 45.5% |
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 Lap-band removal and gastric bypass surgery for treatment of the enrollee, who is status post Lap-band placement. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The Lap-band is a mechanical device which has a high …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation for Lap-Band surgery for evaluation of the enrollee’s obesity and sleep apnea. Findings: The physician reviewer found that this patient is morbidly obese with a BMI of 39.26 kg/m2 on 4/11/16 and 40.4 kg/m2 on 4/20/16. According to the American Association of Clinical Endocrinologists, the …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested an office consultation for treatment of her medical condition. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Although there is a lack of standard guidelines for the criteria for office consultation for weight loss surgery, the requested …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove the enrollee’s Lap-band. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the submitted documentation, the patient desires removal of the Lap-band and conversion to sleeve gastrectomy. However, there is no documentation of …”
- 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 Morbid Obesity overturned?
In 112 California IMR decisions from 2005 to 2017, reviewers overturned 51 (45.5%). 104 were medical-necessity disputes, 8 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.