Panniculectomy for Orth/Musculoskeletal: 30.0% of denials overturned
In 10 California IMR decisions from 2006 to 2023, reviewers overturned 3 (30.0%). In the last five years: 0.0% of 1. 10 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“A 43-year-old female enrollee has requested panniculectomy and abdominoplasty for treatment of her symptomatic abdominal pannus. Findings: The physician reviewer found that based on review of the available records, there is adequate documentation describing a functional impairment likely related to the lower abdominal overhang. A panniculectomy may correct this lower abdominal overhang. The American Society of Plastic Surgeons (ASPS) stated …”
“A 55-year-old female has requested a panniculectomy for treatment of her lipodystrophy. Findings: The physician reviewer found that based on review of the available records, the patient presents with a severely enlarged overhanging pannus, which is an abnormal state of the abdomen. In addition, the patient is being treated for obesity which can be classified as a disease. The records …”
“A 52-year-old female enrollee has requested for a plastic surgery consultation for treatment of her back pain. Findings: The physician reviewer found that it is not reasonable to expect a primary care physician to know the requirements or the nuances of an examination that could provide useful information in that regard. Likewise, it would not be expected that a primary …”
And one the reviewer upheld
“The physician reviewer found that The patient has requested authorization and coverage for panniculectomy. According to national plastic surgery guidelines, 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 be considered cosmetic in nature. Studies noted that …”
- 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 Panniculectomy denials for Orth/Musculoskeletal overturned?
In 10 California IMR decisions from 2006 to 2023, reviewers overturned 3 (30.0%). In the last five years: 0.0% of 1. 10 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.