General Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 58-year-old female with a BMI of over 45 and comorbidities including type 2 diabetes and nonalcoholic steatohepatitis. She has completed an evaluation for bariatric surgery and her candidacy has been approved. In addition to her steatohepatitis, the patient also has evidence of splenomegaly and possible cirrhosis; there is no active ascities at this time. Sleeve gastrectomy has been recommended for surgical weight loss as gastric bypass and Lap Band were rejected because of her underlying liver disease. The patient wishes to undergo laparoscopic sleeve gastrectomy for treatment of her morbid obesity.

Physician 1: The patient is a 60-year-old male with symptoms of prostatism including urinary hesitancy, weak stream, and nocturia. On digital rectal examination he was found to have a significantly enlarged prostate gland. His PSA level was last reported in July 2005 to be normal. The patient has not sufficiently responded to adequate medical, non-operative treatment, which has included three different alpha adrenergic blockers (Cardura, Flomax, and Uroxatral) and a 5-alpha reductase inhibitor (Proscar). He therefore wishes to have surgical treatment of his benign prostatic hypertrophy. His choice of surgical procedure is Holmium laser resection/enucleation of the prostate.

Where the denial was upheld

Physician 1The patient is a 45-year-old female patient with reflux symptoms who has been on multiple proton pump inhibitors (PPIs) and H2 blockers. An EGD performed in October 2002 revealed reflux esophagitis. The patient’s provider has recommended an Enteryx procedure. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental.The efficacy of the Enteryx procedure has not been established. The largest study to date, a multicenter trial of 81 patients, shows 73% of patients who were followed for more than two years had significant improvement in their PPI dependency (Johnson DA, et al.). A recent article in Gastroenterology and Endoscopy News, revealed there is an ongoing open label investigation of the Enteryx procedure with 45-month follow-up data collected from 42 patients.

Physician 1: This patient is a 55-year-old male who has well-documented gastroesophageal reflux disease (GERD) with breakthrough symptoms on a twice daily proton pump inhibitor, which is a standard medical treatment for this condition. Alternative therapies for GERD include endoscopic anti-reflux procedures and surgical anti-reflux therapies. The treating physician has recommended an endoscopic anti-reflux procedure (Stretta) as an alternative therapy. The Health Plan has denied this request on the grounds that the procedure is investigational and experimental.Review of the evidence provided demonstrates this patient is not a candidate for the Stretta procedure, as the device has never been evaluated in clinical studies as a therapy for incomplete responders to medical therapy such as this patient.

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