Mental Hlth Prob denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 16-year-old male (almost 17-years old) with a weight of 508 pounds and a body mass index (BMI) of 79.6. His comorbid conditions include asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence. The patient has completed a psychological evaluation and it was determined that with supportive therapy, he is an appropriate candidate for weight loss surgery. The Health Plan has denied the parent’s request for coverage of bariatric surgery based upon their determination that the procedure is not medically necessary.With a BMI of 79.6 and comorbid conditions such as asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for him.

The patient is a 43-year-old woman with a body mass index (BMI) of 45. In addition, the patient has multiple comorbid conditions. The patient has failed attempts at standard weight loss modalities. The submitted records indicate the patient has undergone three psychological evaluations to determine her suitability for weight loss surgery with varying results. The results of the first two psychological evaluations indicated the patient was not an appropriate candidate for weight loss surgery. However, a third psychological evaluation, which appears to be the most recent, determined the patient met psychological criteria for weight loss surgery. At issue is whether the requested surgery is medically necessary for treatment of the patient’s condition.The patient meets national medical necessity criteria for weight loss surgery based upon her BMI of 45 and documented comorbid conditions.

Where the denial was upheld

The patient is a 56-year-old male with morbid obesity who underwent a lap band procedure in January 2005. The patient lost an initial 30 pounds and has now stopped losing weight. The patient indicates the band is too tight and he is requesting takedown of the band followed by a Roux-en-Y procedure. He has had an outside psychiatric evaluation, but has not completed in-plan counseling. He has arthritic complaints affecting his back and hip. His band has not been adjusted since the procedure was originally performed. The Health Plan has denied authorization for the proposed procedures on the basis they are not medically necessary for treatment of the patient’s condition.At this point the patient is failing to lose weight with a gastric restrictive procedure. This requires an active effort to reduce intake.

The patient is a 58-year-old female who is status post gastric bypass surgery in 1998. She is currently at a weight of 232 pounds with a body mass index (BMI) of 36, and has multiple comorbidities. The patient is requesting authorization for revisional weight loss surgery. The Health Plan has denied this request on the basis that there is no documentation of dietary and lifestyle changes after the first bariatric surgery or evidence of excessive postoperative enlargement of the gastric pouch.Gastric bypass surgery has a slightly greater than 60% success rate, as measured by excess body weight loss at two to five years after surgery.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving mental hlth prob, then check the rights and deadlines that apply to your plan.