Morbid Obesity denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 58-year-old female with a BMI of over 45 and comorbidities including type 2 diabetes and nonalcoholic steatohepatitis. She has completed an evaluation for bariatric surgery and her candidacy has been approved. In addition to her steatohepatitis, the patient also has evidence of splenomegaly and possible cirrhosis; there is no active ascities at this time. Sleeve gastrectomy has been recommended for surgical weight loss as gastric bypass and Lap Band were rejected because of her underlying liver disease. The patient wishes to undergo laparoscopic sleeve gastrectomy for treatment of her morbid obesity.

A 54-year-old female has requested abdominal wall reconstruction/panniculectomy, hernia repair (CPT 49560), breast tissue reconstruction/mastopexy (CPT 19319), and excessive skin removal/whole body lift (CPT 15831 for treatment of her medical condition status post gastric bypass with weight loss. Findings: The physician reviewer found that the excess abdominal tissue of the lower abdomen and ptotic breast tissue should be considered abnormal as a result of obesity and subsequent weight loss. This finding is consistent with the photographs and medical documentation as obesity can be considered a disease. Obesity correction is known to create significant functional deficits as documented in the references. The patient does complain of difficulties with her overlapping tissue of the breasts and abdomen.

Where the denial was upheld

Physician 1: The patient is a 40-year-old female with a body mass index (BMI) of 42 and multiple comorbidities. She has passed medical, surgical and psychological evaluations and requested authorization and coverage for laparoscopic restrictive vertical gastroplasty/lateral sleeve gastrectomy. The Health Plan has denied this request indicating that the efficacy of the requested procedure remains unproven.Restrictive vertical gastroplasty/LSG is a component of the pancreaticobiliary bypass with duodenal switch (PBB/DS) procedure. This procedure is generally appropriate as the first component of a staged PBB/DS in a super morbidly obese patient (BMI greater than 60). There are scattered reports of LSG as sole surgical therapy, however, there is no consistent randomized data to support the efficacy of that application.

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.

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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 morbid obesity, then check the rights and deadlines that apply to your plan.