Bariatric Roux-en-y for Morbid Obesity: 75.0% of denials overturned
In 60 California IMR decisions from 2005 to 2017, reviewers overturned 45 (75.0%). 60 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 33 | 87.9% | 75.0% |
| Guidelines or criteria citedThe findings cite guidelines, criteria or a standard of care. | 3 | 66.7% | 75.0% |
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
“A 27-year-old female has requested bariatric surgery for treatment of her obesity. Findings: The physician reviewer found that review of the submitted documentation demonstrates the patient meets medical necessity criteria for weight loss surgery. She meets all standard accepted guidelines for bariatric surgery such as the National Institutes of Health (NIH) consensus guidelines. She is over 18 and has clinically …”
“A 37-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her morbid obesity. Findings: The physician reviewer found that the documentation demonstrates that this patient meets all standard, generally accepted criteria for bariatric surgery, including the National Institutes for Health guidelines. She is morbidly obese with a BMI of 48.23, has failed weight loss efforts and …”
“A 25-year-old female enrollee is requesting a Laparoscopic conversion from Gastric Banding (LAGB) to Roux-en-Y Gastric Bypass (RYGBP) for the treatment of her medical condition. Findings: The physician reviewer found that the LAGB has been documented to be a source of dietary intolerance with dysphagia without any overt findings on diagnostic studies. When dietary and behavioral non-compliance are ruled out, …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Roux-en-Y gastric bypass surgery for treatment of the enrollee’s obesity. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Not all patients will be determined to be appropriate candidates for bariatric surgery despite meeting body mass index …”
- 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 Roux-en-y denials for Morbid Obesity overturned?
In 60 California IMR decisions from 2005 to 2017, reviewers overturned 45 (75.0%). 60 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.