Gastric Bypass denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 44-year-old male who has a body mass index (BMI) of 45.6. In addition, the patient has several comorbid conditions including sleep apnea, degenerative arthritis, and gastroesophageal reflux disease. There is no evidence that the patient has undergone a psychiatric consultation. A request has been made for gastric bypass surgery. The Health Plan has denied the request on the basis that gastric bypass surgery is not medically necessary.With a BMI of 45.6 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patient’s morbid obesity.

The patient is a 37-year-old female with a body mass index (BMI) of 44.9. She has obesity-related comorbidities including urinary stress incontinence and gastroesophageal reflux disease. She wishes to undergo gastric bypass. It does not appear that she has undergone a psychological evaluation to assist in determining whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary.With a BMI of 44.9 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Weight loss surgery is medically indicated and necessary for treatment of this patient’s morbid obesity.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: EE requested authorization and coverage for weight loss surgery consultation for gastric bypass. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patient’s case. Although this patient is morbidly obese and has a symptomatic ventral hernia that cannot be repaired without substantial weight loss, bariatric surgery has not been determined to be medically necessary. There is no dietary evaluation or psychological evaluation that has documented this patient’s compliance with necessary lifestyle changes and there is no evaluation of stability from substance abuse. The medical necessity cannot be determined without documentation of a thorough multidisciplinary evaluation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a second gastric bypass surgery for treatment of her medical condition. Findings: Three physician reviewers found that a review of the medical records provided indicates that this patient has already undergone gastric bypass surgery. There is a lack of support for a second gastric bypass surgery in this clinical setting. Perioperative compliance is essential to weight loss after Roux-en-Y gastric bypass. Since this patient has demonstrated recurrent weight gain despite bypass, repeat bypass is not recommended by current bariatric guidelines. Repeat bypass surgery is not standard of care and carries a high risk of dumping syndrome as well as other perioperative complications. Thus, the requested second gastric bypass surgery is not likely to be of greater benefit than other treatment options.

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