Bariatric Roux-en-y denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 53-year-old female with a body mass index (BMI) of 56.2 and significant comorbid conditions. Additionally, she has motility and obstructive problems resulting from her gastric stapling over 25 years ago. The patient has completed a psychological evaluation and was deemed an acceptable candidate for weight loss surgery. The Health Plan has denied coverage for revisional gastric bypass surgery based upon their determination that the procedure is not medically necessary for treatment of the patient’s morbid obesity and gastrointestinal problems.With a BMI of 56.2 and comorbid conditions such as gastric stasis, depression, gastroesophageal reflux disease, obstructive sleep apnea, hypertension, diabetes mellitus, venous insufficiency, and degenerative joint disease the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery.

This patient is a 66-year-old female who is status post vertical banded gastroplasty (VBG) with subsequent weight regain. At present, her BMI is 48 and she has obesity related comorbidities such as type 2 diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and depression. She has had some transient weight loss with diet. Upper GI series and endoscopy suggests that the VBG has broken down. The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patient’s provider recommends gastric bypass surgery and has submitted a request for authorization.

Where the denial was upheld

The patient is a 46-year-old female who is 5’1” weighing 240 pounds with a body mass index (BMI) of 45. She has comorbid conditions of hypertension, asthma, and osteoarthritis. She is status post Nissen fundoplication. She has been approved for bariatric surgery on the condition that she loses weight preoperatively and attends support group meetings. She has not complied with these conditions. Based upon the information provided, she has not been evaluated by a bariatric surgeon since 2004. In addition, it is unclear when the patient underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions the patient meets accepted criteria for consideration of weight loss surgery.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Roux-en-Y gastric bypass surgery for treatment of the enrollee’s obesity. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Not all patients will be determined to be appropriate candidates for bariatric surgery despite meeting body mass index metrics to meet definition for morbid obesity. Although this patient is an adult with morbid obesity, she was not determined to be an appropriate candidate after completion of a multidisciplinary evaluation at this time. Per the records, she was not found to have obtained psychological clearance. Therefore, the risks of surgery outweigh the potential benefits at this time.

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 Roux-en-y, then check the rights and deadlines that apply to your plan.