Laparoscopic Adjustable Gastric Banding denials in California external review
In the California DMHC record, independent physician reviewers decided 26 published external-review cases involving Laparoscopic Adjustable Gastric Bandingand overturned the plan’s denial in 53.8%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Laparoscopic Adjustable Gastric Banding denials
| Category | Decisions | Overturned |
|---|---|---|
| Morbid Obesity | 16 | 68.8% |
| Obesity | 9 | 33.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 23 | 52.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
A 37-year-old female enrollee has requested laparoscopic adjustable gastric banding surgery for treatment of her obesity. Findings: The physician reviewer found that the patient’s chart demonstrates that she has tried many diets in the past but was unable to maintain the weight loss. Several years ago she did lose some weight, but in the past couple of years, both her weight and BMI have increased. The American Society of Bariatric Surgery (ASBS) 2004 consensus conference statement, “As long as a candidate has tried to lose weight by various means they should not be required to complete formal non-operative obesity therapy as a precondition for bariatric surgery”(Buchwald). The authors also commented that, “Long-term weight loss is difficult to achieve with diet, exercise, and pharmacotherapy.
A 57-year-old female enrollee has requested for laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity without participation in the Options program. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 44.6 and significant comorbidities that will likely be ameliorated or eliminated by bariatric surgery. She requires immunosuppression and medications that may inhibit the healing process due to her severe arthritis, making the Lap Band procedure the most appropriate surgical alternative for weight loss. With regard to the Positive Choice program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese.
Where the denial was upheld
The patient is a 16 year-old female who weighs 280 pounds and has a body mass index of 47. She has demonstrated various pre-diabetic conditions along with hypertension, hyperlipidemia, irregular menses, asthma and obstructive sleep apnea. The patient is currently treated for depression and takes several psychotropic medications. Her psychiatrist recommends the Lap Band procedure. The patient’s parents have submitted a request for authorization of laparoscopic adjustable gastric banding to the Health Plan. The Health Plan does not consider this procedure medically necessary, and has denied the parents’ request.Lap Band studies in the United States have not produced the same results in terms of maintaining excess body weight loss (EBWL) as the European or the Australian Studies. The reason for this difference is not well defined.
The patient is a 48-year-old male with a weight of 290 pounds and a body mass index (BMI) of 38. His comorbid conditions include Type II diabetes mellitus, hyperlipidemia, hypertension, obstructive sleep apnea, and gastro-esophageal reflux disease (GERD). He has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. He has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) which the Health Plan has denied based upon their determination that it is not medically necessary for treatment of the patient’s morbid obesity.The Lap Band procedure has been promoted as a low risk, easy operation to perform. Patients can however, experience complications after surgery with this procedure. Most complications are not serious but some may require re-hospitalization and/or re-operation.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Laparoscopic Adjustable Gastric Banding, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY