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Bariatric Other denials: what the review data shows
Independent reviewers have decided 174 published cases where an insurer denied Bariatric Other — and they overturned the insurer 51.1% of the time. A denial for Bariatric Other is a starting position, not a final answer.
Published decisions
174
2001–2026
Overturned
51.1%
89 denials reversed
Conditions behind bariatric other denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Hypertension | 52 | 57.7% |
| Musculoskelet Ortho | 21 | 47.6% |
| Cardiac Problem | 6 | 66.7% |
| Mental Hlth Prob | 5 | 60% |
| Obesity | 4 | 75% |
| Post Surg Complicat | 3 | 66.7% |
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. | 131 | 50.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 43 | 53.5% |
Typical time to a decision
21 days
Most land between 15 and 22 days
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
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
Worth reading too — these show what an appeal has to overcome.
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).
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 treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Bariatric Otherwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.