Gastric Bypass Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lap-band removal and gastric bypass surgery for treatment of the enrollee, who is status post Lap-band placement. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The Lap-band is a mechanical device which has a high explant rate secondary to complications related to the device, failure of the device to result in intended weight loss and/or intolerance to the device. This patient has worsening gastroesophageal reflux disease. Per the medical records, she requires Lap-band removal to prevent secondary complications of prolapse, erosion and slippage. Therefore, the requested Lap-band removal is medically necessary for the treatment of this patient.

The patient is a 63-year-old female requesting authorization for bariatric surgery without meeting the Health Plan’s weight loss requirement. In December 2004 her weight was 234.7 pounds with a body mass index of 41.5. The Health Plan required a 10% weight loss which established a goal weight of 211 pounds for authorization of weight loss surgery. After cessation of smoking, the patient gained additional weight and now must lose 49 pounds. The patient’s co-morbid conditions include obstructive sleep apnea, hypertension, osteoarthritis and depression. She has completed a psychological evaluation and was deemed a good candidate for weight loss surgery. The patient has requested authorization for bariatric surgery based on a modified preoperative weight loss requirement.

Where the denial was upheld

The patient is a 16-year-old female with a significant history of obesity and family obesity. She is reported to weigh 300 pounds with a BMI of 44. She has been overweight since age seven. She has made multiple attempts at non-surgical weight loss without success and with weight gain. She has comorbidities including hypertension and asthma. The patient’s mother has requested authorization for gastric bypass surgery to treat the patient’s morbid obesity.Although there are surgeons and surgical centers specializing in bariatric surgery for adolescents, there is a limited amount of scientific evidence regarding bariatric surgery in adolescent patients. Significant concerns involving adolescent patients and bariatric surgery include growth retardation and behavior modification.

A 48-year-old male enrollee has requested authorization and coverage for gastric bypass surgery. The patient has a body mass index (BMI) of 46. His comorbidities include hyperlipidemia, degenerative disc disease, bladder incontinence, diabetes mellitus, sleep apnea, and depression. He has requested authorization for gastric bypass surgery. The Health Plan states the patient needs to obtain psychological clearance and undergo nutritional counseling before weight loss surgery can be authorizedWith a BMI of 46 and comorbid conditions, the patient is likely to benefit from gastric bypass surgery. He does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese.

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