Lap-band Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 57-year-old female who has a BMI of 41. In addition, she has the comorbid condition of stress incontinence. She is seeking Lap-Band surgery for weight loss surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan considers Lap-Band an experimental procedure and has denied authorization.Lap-Band is the leading form of weight loss surgery worldwide. Early studies were primarily from Europe and Australia. The first American studies showed a high rate of band slippage and inferior short-term weight loss. As more experience has been gained in the United States, the complication rate has dropped to below that of Roux-en-Y gastric bypass.

A 43-year-old female enrollee has requested lap-band surgery for the treatment of her morbid obesity. Findings: The physician reviewer found that this patient has a BMI of 42.2 and multiple co-morbid conditions, therefore, she meets the National Institutes of Health (NIH) criteria for bariatric surgery. The Health Plan indicates that the patient must obtain a presurgical weight of 253 pounds before surgery can be approved. Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for treatment of morbid obesity. There is no scientific data to support delayed surgical intervention in this setting. In the case of this patient, she is seeking authorization for the lap-band procedure.

Where the denial was upheld

Physician 1: The patient is a 57-year-old female who had a body mass index (BMI) of 37. In addition, she had multiple comorbidities. Her cholesterol/HDL ratio was in the normal range. She was on single drug treatment for hypertension. The patient was less than 100 pounds over ideal body weight. The patient underwent Lap-Band surgery in September 2004. The Health Plan has denied coverage for the Lap-Band on the basis it is considered investigational.With a BMI of 37 and no severe comorbidities, the patient did not meet nationally accepted medical necessity criteria for weight loss surgery. Her BMI was less than 40 and her comorbidities did not rise to the level to justify operative intervention of any type. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

A 57-year-old female enrollee has requested a consultation regarding lap band surgery for an evaluation of her obesity. Findings: The physician reviewer found that the patient does not meet the criteria set by the National Institutes of Health (NIH) consensus statement for bariatric surgery. It has not been sufficiently established that the patient has the co-morbidity criteria that would require such surgery combined with her BMI of 38. There are discrepancies in the record regarding whether the patient has obstructive sleep apnea. Although one submitted criteria checklist for bariatric surgery candidates notes that the patient has a co-morbidity (among others) of moderate obstructive sleep apnea, a copy of that checklist does not have the co-morbidity of sleep apnea checked. In addition, there is no documentation of a diagnosis of sleep apnea anywhere in the records provided.

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