Musculoskelet Ortho denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bariatric surgeon consultation. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s morbid obesity. A review of the record indicates that the enrollee has been diagnosed with schizoaffective disorder bipolar type; asthma; alcohol use disorder; hypertension; diabetes; and morbid obesity. A progress note dated 7/27/18, reported the enrollee presented for a psychiatric evaluation for gastric bypass procedure. The provider reported the enrollee had tried multiple diets, diet pills (Hydroxycut), and exercises regularly without losing significant weight. The enrollee denied binge eating and purging.

A 28-year-old female has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings: The physician reviewer found that this patient meets generally accepted guidelines for bariatric surgery based on National Institutes of Health criteria. At issue is whether the duodenal switch procedure is medically necessary for treatment of the patient’s morbid obesity as opposed to available surgical alternatives. The duodenal switch procedure is a reasonable and appropriate treatment option for morbid obesity in the well selected candidate. It is a standard primary treatment for morbid obesity, and is approved by the American Colleges of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services. Duodenal switch is well-accepted as a safe procedure.

Where the denial was upheld

Physician 1: The patient is a 45-year-old female with a body mass index (BMI) of 44. She has multiple comorbidities. She has requested authorization and coverage for laparoscopic restrictive vertical gastroplasty/gastrectomy. The Health Plan has denied this request indicating that the efficacy of the requested procedure remains unproven.Restrictive vertical gastroplasty/gastrectomy is generally appropriate as a component of a staged procedure in the super obese (BMI greater than 60). As an isolated procedure, there are no large studies to confirm its long-term efficacy. The American Society of Bariatric Surgeons does not recognize restrictive vertical gastroplasty/gastrectomy as an isolated bariatric procedure. Furthermore, the requested procedure does not fall within the Health Plan guidelines of approved bariatric procedures.

Physician 1: The patient is a 51-year-old female weighing 335 pounds with a body mass index (BMI) of 61. She has a number of comorbid conditions including hypertension, obstructive sleep apnea, and degenerative joint disease. The patient’s provider has recommended laparoscopic vertical gastroplasty/gastrectomy. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is more than adequate data regarding the requested procedure. All the published data show a higher failure rate for the requested procedure (greater than 50%) over the life of the operation. In fact, vertical gastroplasty/gastrectomy has a high revision rate compared to other weight loss procedures.

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 musculoskelet ortho, then check the rights and deadlines that apply to your plan.