Bariatric Other 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral arm lift (brachioplasty), breast lift (mastopexy), thigh lift (thighplasty), and panniculectomy for treatment of the enrollee’s weight loss status post bariatric surgery. Findings: The physician reviewer found that the records indicate that this patient experienced significant weight loss following bariatric surgery. Based on the documentation provided, a clear functional deficit has not been defined related to her excess soft tissue and skin overlap of the arms, breasts, abdominal pannus and thighs. Photographs show evidence of mild soft tissue excess of the arms, Grade II/III ptosis of the breasts, an overhanging lower abdominal pannus and severe soft tissue excess of the thighs.

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: This patient is a 50-year-old female with a body mass index (BMI) of 44.3. She has had the appropriate evaluations and is considered to be a viable candidate for bariatric surgery. The patient’s provider offered multiple options for the weight loss surgery and the patient has chosen an isolated vertical gastrectomy as her procedure of choice. The patient now requests authorization for the selected surgical procedure. The Health Plan considers the vertical gastrectomy (gastroplasty) experimental/investigational and has denied authorization and coverage.The vertical gastrectomy is now utilized as a component of the pancreaticobiliary bypass with duodenal switch (PBB/DS).

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 Bariatric Other, then check the rights and deadlines that apply to your plan.