Revision Procedures for Endocrine/Metabolic: 40.0% of denials overturned
In 5 California IMR decisions from 2020 to 2023, reviewers overturned 2 (40.0%). In the last five years: 0.0% of 3. 5 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 1 | 0.0% |
| 2022 | 1 | 0.0% |
| 2023 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731). Thompson and colleagues studied the safety and efficacy of transoral outlet reduction for the treatment of weight regain in Roux-en-Y gastric bypass patients. Weight loss or stabilization was achieved in 96% of patients six …”
“The patient has requested authorization and coverage for revision of previous bariatric surgery (gastric bypass) excluding lap band. Researchers reported the evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. The authors also reported that purse-string transoral outlet reduction (TORe) to treat weight regain after RYGB is technically …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for distal bypass revisional surgical procedure (laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy and esophagogastroduodenoscopy, flexible, transoral with biopsy). On review of the available medical records, there is a lack of support for the requested surgical intervention for this patient. Distalization of the gastric …”
- 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 Revision Procedures denials for Endocrine/Metabolic overturned?
In 5 California IMR decisions from 2020 to 2023, reviewers overturned 2 (40.0%). In the last five years: 0.0% of 3. 5 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.