Gastric Bypass for Morbid Obesity: 62.1% of denials overturned
In 198 California IMR decisions from 2001 to 2005, reviewers overturned 123 (62.1%). 155 were medical-necessity disputes, 43 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. | 44 | 25.0% | 62.1% |
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 32 | 93.8% | 62.1% |
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 32-year-old female who is 5’2” and 221 pounds with a body mass index (BMI) of 40.4. She has engaged in multiple attempts over the years to lose weight, all of which have failed. It does not appear the patient has obtained psychiatric clearance. The patient has requested authorization for gastric bypass surgery. The Health Plan has …”
“Physician 1: The patient is a 57-year-old female who has a BMI of 41. In addition, she has the comorbid condition of stress incontinence. She is seeking Lap-Band surgery for weight loss surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan considers Lap-Band an experimental procedure and has …”
“The patient is a 56-year-old female who has failed conventional medical therapy. She has arthritis as a component of her comorbidities and is taking NSAIDs. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied the patient’s request on the basis that duodenal …”
And one the reviewer upheld
“The patient is a 56-year-old female with a body mass index (BMI) of 38. The patient’s provider indicates the patient has comorbid conditions including diabetes, gastroesophageal reflux disease, and osteoarthritis. The patient has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates weight loss surgery is not medically necessary for …”
- 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 Gastric Bypass denials for Morbid Obesity overturned?
In 198 California IMR decisions from 2001 to 2005, reviewers overturned 123 (62.1%). 155 were medical-necessity disputes, 43 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.