SCP Consult Refer for Morbid Obesity: 66.7% of denials overturned
In 27 California IMR decisions from 2001 to 2017, reviewers overturned 18 (66.7%). 27 were medical-necessity disputes.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 6 | 83.3% | 66.7% |
| Records did not supportThe findings say the documentation did not show what was needed (usually an upheld denial). | 5 | 0.0% | 66.7% |
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: The parent of an enrollee has requested authorization and coverage for a bariatric surgery consultation for treatment of the enrollee’s abdominal pain, obesity, and diabetes mellitus. Findings: The physician reviewer found that the records document that this patient meets the current criteria for consideration of adolescent bariatric surgery, as she has a BMI of 52.8 …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin. Findings: The physician reviewer found that the requested lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin is medically necessary for treatment of the patient’s medical condition. According to a study “The abdominal panniculus …”
“The parent of a 17-year-old female enrollee has requested authorization and coverage for a bariatric surgery consultation. The Health Plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the enrollee’s morbid obesity. Findings: The physician reviewer found that per the adolescent bariatric surgery guidelines, adolescents who are potential candidates for bariatric surgery …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a surgical weight loss specialist. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity for the requested services in this clinical setting. Bariatric surgery is currently reserved for treatment of morbid obesity. However, in this patient’s case, a …”
- 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 SCP Consult Refer denials for Morbid Obesity overturned?
In 27 California IMR decisions from 2001 to 2017, reviewers overturned 18 (66.7%). 27 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.