Excess Skin Removal for Morbid Obesity: 27.5% of denials overturned
In 40 California IMR decisions from 2005 to 2018, reviewers overturned 11 (27.5%). 40 were medical-necessity disputes.
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). | 22 | 13.6% | 27.5% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 11 | 18.2% | 27.5% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 8 | 50.0% | 27.5% |
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 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 …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reconstructive surgery for removal of excess skin on breast, abdomen, and arms for treatment of the enrollee’s excess skin. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The medical records document massive weight loss. She has evidence of functional …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for excess skin removal surgery. Findings: The physician reviewer found that The medical records note significant weight loss following bariatric surgery. The patient is documented to have evidence of excess skin of the abdomen, breasts and buttocks. However, the submitted photographs indicate that these conditions were mild. Her functional problems …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excess thigh skin removal. The records do not establish the medical necessity for the proposed thigh dermatolipectomies. The thigh dermatolipectomies are proposed as a treatment for recurrent infections, but the records do not include objective evidence of recurrent infections in the patient’s history. Specifically, the medical records …”
- 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 for Morbid Obesity overturned?
In 40 California IMR decisions from 2005 to 2018, reviewers overturned 11 (27.5%). 40 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.