Bariatric Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bariatric surgery. Goetze and colleagues report that there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery. Diggins and Heinberg report, “There are still many unanswered questions regarding marijuana use and bariatric surgery, and the limited literature base has produced mixed results when considering marijuana as a contraindication for bariatric surgery.” While the consumption of cannabis is currently legal for medical and nonmedical use in numerous states, there is a lack of published literature within the bariatric field supporting stringent abstinence requirements due to a paucity of evidence.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery for treatment of the enrollee, who has a history of morbid obesity and gastroesophageal reflux. Findings: The physician reviewer found that the patient’s BMI is 37 kg/m2, which is greater than 20 percent weight loss. The patient also has symptoms of GERD. She is status post gastric banding. She has plateaued and is unable to behaviorally manage her weight loss. She also has polycystic ovary syndrome (PCOS), which is aggravated by her obesity. The records also show that this patient has tried other treatment options to address her weight loss. She has demonstrated that the gastric band is not effective in her case. She has not tolerated, but did try, phentermine. The records also demonstrate that she has tried to stay on a restrictive diet.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery.According to Mechanick and colleagues, “Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity.” Arterburn and colleagues indicate that National Institutes of Health guidelines “recommend consideration of bariatric surgery in patients with BMI of 40 or higher or 35 or higher with serious obesity-related comorbidities.” Additionally, the authors state that, “Bariatric procedures should also be considered for patients with type 2 diabetes and a BMI of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment.” In this case, the patient does not present with clinically severe or morbid obesity.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for authorization and coverage for bariatric surgery. Findings: According to the American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) guidelines, metabolic and bariatric surgery is recommended for patients with a body mass index (BMI) over 35 kg/m2, regardless of the presence, absence, or severity of comorbidities. Additionally, the ASMBS and IFSO guidelines state that metabolic and bariatric surgery should be considered for patients with a history of metabolic disease and a BMI of 30-34.9 kg/m2. The records provided for review fail to document that the patient has a history of metabolic disease.

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