Bariatric Surgery Consultation denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 58-year-old male who has requested authorization for a bariatric surgery consultation. He is 6’1”, weighs 329 pounds, and has a body mass index (BMI) of 43.4. In addition, he has significant comorbid conditions. The Health Plan has denied authorization and coverage for the consultation with a bariatric surgeon based upon their determination that it is not medically necessary for treatment of the patient’s medical condition.With a BMI of 43 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for this patient. The fact that there is no documentation of medically supervised weight loss should not preclude a consultation for bariatric surgery.

The patient is a 59-year-old female with a body mass index (BMI) of 52.4. She has multiple comorbidities including asthma and peripheral vascular disease. The patient has outlined failed attempts at weight loss with both supervised and unsupervised programs. She has requested authorization for a bariatric surgery consultation. The Health Plan has denied this request citing a lack of documented evidence the patient has participated in a medically supervised nutrition and exercise program.With a BMI of 52 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a consultation with a surgeon. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. A review of the records indicates that the enrollee has been diagnosed with chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. The enrollee’s provider noted that the enrollee had been using a wheelchair. Knee pain was also noted. The enrollee was noted to have tried dieting but was unsuccessful with weight loss. The enrollee bariatric was 5 feet 7 inches tall, and weighed 323.3 pounds. The enrollee’s body mass index (BMI) was 50.62.

The patient is a 36 year-old female who is 5’3” tall weighing 280 pounds. Review of the submitted clinical information does not demonstrate that the patient has any life threatening comorbidities. The patient does have obesity related comorbidities that will improve with surgery. The submitted information indicates the patient continues to smoke. Evidence of a psychiatric evaluation has not been provided. The patient has requested that she receive a timelier consultation for bariatric surgery. The patient also indicates that she wishes to undergo duodenal switch gastric bypass rather than the Roux-en-Y procedure.A wait of six months for an appointment and up to a year before surgery is not uncommon and is consistent with many bariatric surgical programs.

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