Excess Skin Removal denials: 28.8% overturned by independent reviewers
In 59 California IMR decisions from 2005 to 2019, reviewers overturned the plan 17 times (28.8%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Morbid Obesity | 40 | 27.5% | — |
| Skin Disorders | 8 | 37.5% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 31 | 12.9% | 28.8% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 12 | 16.7% | 28.8% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 10 | 40.0% | 28.8% |
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 tummy tuck or mid body lift. The American Society of Plastic Surgeons (ASPS) states that “when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excision of excessive skin, tissue and suction assisted lipectomy in both upper extremities for treatment of the enrollee’s overgrowth of her upper arms and are not reconstructive in nature. Findings: The physician reviewer found that Based on the documentation provided, the patient has sufficient evidence of functional …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominal lipectomy.Findings: The physician reviewer found that the patient has well-documented scenario of a symptomatic, abdominal pannus that has failed reasonable conservative management. Her symptoms include back and abdominal pain that affect her activities of daily living. Work-up of her abdominal pain has included a CT scan …”
- 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 Excess Skin Removal denials overturned?
In 59 California IMR decisions from 2005 to 2019, reviewers overturned the plan 17 times (28.8%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
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 the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
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.