Bariatric Surgery for Morbid Obesity: 37.5% of denials overturned
In 24 California IMR decisions from 2001 to 2005, reviewers overturned 9 (37.5%). 13 were medical-necessity disputes, 11 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 11 | 18.2% | 37.5% |
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
“The patient is a 33-year-old female who is 5’8” tall and weighs 280 pounds with a body mass index (BMI) of 44.1. She is requesting authorization for a consultation with a bariatric surgeon. The patient has a multitude of comorbid conditions compounding her morbid obesity. She has a history of multiple attempts at weight loss including physically supervised plans as …”
“The patient is a 21-year-old female with a body mass index (BMI) of 55. She is requesting authorization for gastric bypass surgery. The patient also has a number of comorbid conditions. The patient indicates she has made multiple attempts to lose weight without long-term success. The Health Plan indicates it is medically necessary for the patient to meet her preoperative …”
“The patient is a 46-year-old female with a body mass index (BMI) of 49. She has comorbid conditions of hypothyroidism and hypertension. She has requested authorization for bariatric surgery. She has not undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied the patient’s request.With a BMI of 49 …”
And one the reviewer upheld
“The patient is a 55-year-old female seeking abdominoplasty for a hanging panniculus post gastric bypass, which apparently was performed in 1986. The patient’s stated weight is 151 pounds and her height is 60” indicating a body mass index of greater than 30. This suggests that the patient’s weight loss surgery has failed. The Health Plan has denied coverage for an …”
- 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 Surgery denials for Morbid Obesity overturned?
In 24 California IMR decisions from 2001 to 2005, reviewers overturned 9 (37.5%). 13 were medical-necessity disputes, 11 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.