Bariatric Other for Endocrine/Metabolic: 83.3% of denials overturned
In 6 California IMR decisions from 2002 to 2018, reviewers overturned 5 (83.3%). 5 were medical-necessity disputes, 1 experimental/investigational.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery. This patient is an adult who began evaluation for bariatric surgery with documentation of obesity with a BMI that was at least 35 kg/m2, and has ranged from 38-39 kg/m2, with serious comorbid conditions including diabetes, sleep apnea, and hypertension. The patient completed supervised weight …”
“A 37-year-old female enrollee has requested bariatric revision surgery (duodenal switch) for treatment of her obesity. Findings: The physician reviewer found that the medical literature supports the opinion that the performance of a revisional procedure similar to the initial operation will fail in many instances, because the basic problem is metabolic and not mechanical. Rapid gastric emptying, as seen in …”
“A 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the requested procedure is medically …”
And one the reviewer upheld
“A 53-year-old female requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollee’s morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment …”
- 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 Other denials for Endocrine/Metabolic overturned?
In 6 California IMR decisions from 2002 to 2018, reviewers overturned 5 (83.3%). 5 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.