Liposuction for Infectious Disease: 33.3% of denials overturned
In 6 California IMR decisions from 2004 to 2018, reviewers overturned 2 (33.3%). 6 were medical-necessity disputes.
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the trunk (CPT 15877) and neck (CPT 15876). This patient presents with evidence of severe lipodystrophy of the neck and back as a likely complication of her treatment for congenital HIV. Liposuction is supported in the medical literature for use to treat deformities in a …”
“A 49-year-old female enrollee has requested liposuction of fatty tissue for treatment of her lipodystrophy. Findings: The physician reviewer found that lipodystrophy of the posterior neck is a well-recognized complication of HIV and anti-viral therapy. The medical literature confirms that patients with neck lipodystrophy often experience pain and difficulty breathing. The submitted letter from the patient and an office note …”
And one the reviewer upheld
“A 59-year-old female enrollee has requested liposuction of the abdomen, thighs and/or buttocks for treatment of her lipodystrophy. Findings: The physician reviewer found that based on the records provided, the patient’s condition would not constitute an abnormal structure of the body. Further, the recommended liposuction is being requested to improve the patient’s appearance, but there is no documentation in the …”
- 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 Liposuction denials for Infectious Disease overturned?
In 6 California IMR decisions from 2004 to 2018, reviewers overturned 2 (33.3%). 6 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.