Laparoscopic Gastric Banding denials in California external review

What the reviewers wrote

Where the denial was overturned

A 57-year-old female enrollee has requested laparoscopic gastric banding surgery for treatment of her obesity, hypertension, and incontinence. Findings: The physician reviewer found that based on review of the available records, this patient meets all standard nationally published guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines for the requested surgery. She has morbid obesity with a BMI of at least 35 and serious co-morbid conditions. She has hypertension. In addition, she completed a multidisciplinary evaluation and was not determined to have any obvious medical, dietary or behavioral barriers to surgery. She has failed dietary efforts in the past and is requesting a standard primary treatment for morbid obesity.

A 37-year-old male has requested laparoscopic gastric banding (Lap Band) surgery for treatment of his obesity. Findings: The physician reviewer found that based on review of the available records, this patient meets all generally accepted criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. Specifically, the patient has a documented BMI that is greater than 35, and co-morbid conditions including obstructive sleep apnea, asthma, and GERD. The patient has reportedly failed dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. Consistent with these findings, the requested surgery is supported as medically necessary for treatment of this patient’s medical condition.

Where the denial was upheld

A 35-year-old female enrollee has requested authorization and coverage for laparoscopic banding bariatric surgery. Findings: The physician reviewer found that based on review of the available records, the patient has a history of obesity with a BMI between 32 and 36 over the last 4 years. The patient’s current weight is 202 pounds with a BMI of 35. The patient reports a variety of medical attempts at weight loss with mild temporary relief with weight regain. She reports medical conditions including asthma, allergies, fibromyalgia, and pituitary adenoma with underlying psychiatric issues of generalized depression, anxiety, and bipolar disorder with mania.

A 26-year-old female enrollee has requested a bariatric surgical procedure, laparoscopic gastric banding (lap band) for the treatment of her medical condition. Findings: The physician reviewer found that obesity has to be considered a multi-factorial chronic disease which develops from an interaction of genetic and environmental factors. This eventually leads to serious co-morbidities. At the present time, the patient’s only complaint is lower back pain. The ASBS Consensus Conference states that class I and II obese individuals treated conservatively can achieve acceptable results in 10-40% of the cases. The degree of success depends greatly on the weight loss program design, which should include proper supervision with intense behavioral modification and exercise along with possible use of medication.

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