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Cardiac Problem: when insurers say no, reviewers often say yes
In 38 published external-review decisions involving cardiac problem, independent physician reviewers overturned the insurer’s denial 63.2% of the time.
Published decisions
38
2001–2026
Overturned
63.2%
24 denials reversed
Most-fought treatments for cardiac problem
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Bariatric Lap Band | 11 | 72.7% |
| Bariatric Other | 6 | 66.7% |
| Bariatric Roux-en-y | 6 | 83.3% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 31 | 64.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 7 | 57.1% |
Typical time to a decision
21 days
Most land between 20 and 21 days
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Physician 1The patient is a 48-year-old male with a BMI of 70.4. The patient has multiple comorbid conditions including hypertension, severe obstructive sleep apnea, and gastroesophageal reflux disease. He has failed conservative weight loss measures. The patient has requested authorization for vertical restrictive gastrectomy/gastroplasty. The Health Plan has denied the patient’s request indicating a vertical restrictive gastroplasty is considered investigational.Super morbidly obese patients are high operative risks. Therefore, a staged procedure is appropriate in this patient. Although there is support for the duodenal switch procedure in the super obese, which can be performed open as a single stage, this carries the risk of high morbidity. In addition, a purely laparoscopic duodenal switch is very difficult in the super obese.
The patient is a 45-year-old female with a body mass index (BMI) of 43 who is seeking authorization for weight loss surgery. She has multiple comorbid conditions including diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. The information provided indicates the patient has not undergone a psychological examination. The Health Plan has denied authorization for the requested surgery on the basis it is not medically necessary for treatment of the patient’s medical condition.With a BMI of 43 and significant comorbidities, the patient meets nationally accepted guidelines for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician #1: The patient is a 27-year-old male with a BMI of 68.6. His comorbid conditions include heart failure, hypertension, degenerative joint disease, incontinence and gastroesophageal reflux disease (GERD). The patient has tried different diets and they have been listed in the medical record. He has also passed his psychosocial evaluation and is a candidate for bariatric surgery. After reviewing the surgical alternatives with his provider, the patient has requested authorization for laparoscopic vertical gastroplasty/gastrectomy. His request was denied by the Health Plan due to their conclusion that the procedure is experimental.In light of the patient’s high-risk clinical status and his super morbid obesity, the possibility of multiple surgeries does not seem to be the best and safest approach.
The patient is a 48-year-old male with a weight of 290 pounds and a body mass index (BMI) of 38. His comorbid conditions include Type II diabetes mellitus, hyperlipidemia, hypertension, obstructive sleep apnea, and gastro-esophageal reflux disease (GERD). He has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. He has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) which the Health Plan has denied based upon their determination that it is not medically necessary for treatment of the patient’s morbid obesity.The Lap Band procedure has been promoted as a low risk, easy operation to perform. Patients can however, experience complications after surgery with this procedure. Most complications are not serious but some may require re-hospitalization and/or re-operation.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for cardiac problem was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.