Laparoscopic Sleeve Gastrectomy denials in California external review
In the California DMHC record, independent physician reviewers decided 34 published external-review cases involving Laparoscopic Sleeve Gastrectomyand overturned the plan’s denial in 73.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Obesity | 14 | 85.7% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 20 | 80% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 14 | 64.3% |
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.
Nature of Statutory Criteria/Case Summary: This patient has a history of sleep apnea, gastroesophageal reflux disease (GERD), and degenerative joint disease (DJD). A psychological evaluation was obtained on 8/15/17 and did not reveal any obvious barriers to surgery. A dietary evaluation was obtained on 1/22/18 and did not reveal any obvious barriers to surgery. A sleep study was performed on 1/15/19 and revealed moderate obstructive sleep apnea hypopnea with an apnea hypopnea index (AHI) of 22.3. Progress notes dated 3/20/19 reported the patient is 64 inches tall and weighed 217 pounds, resulting in a body mass index (BMI) of 37.25 kg/m2. There is no medication for hypertension noted. The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy.
Where the denial was upheld
A 48-year-old female enrollee has requested laparoscopic gastric band placement (CPT 43770) or laparoscopic sleeve gastrectomy (CPT 43775) for treatment of her obesity. Findings: Two physician reviewers found that the records indicate that she has failed self-attempted diets and weight loss programs and was seen in consultation for weight loss surgery. The provider noted the patient was an appropriate candidate for weight reduction surgery and recommended laparoscopic gastric band placement and if not feasible, laparoscopic sleeve gastrectomy. The patient also sought orthopedic consultation for left knee pain and was diagnosed with “probable degenerative meniscus tear and non-ideal BMI”. Weight reduction surgery is indicated for patients with a BMI greater than 40, or a BMI greater than 35 with significant medical co-morbidities.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy. The records provided for review document that this patient has a BMI that is 35 kg/m2 without documentation of an associated serious obesity-related comorbid condition to support an indication for the requested bariatric surgical procedure (Mechanick, et al.). The patient has obtained surgical clearances from her dietary and behavioral health providers. However, there is no report of a serious obesity-related condition such as type 2 diabetes mellitus, hypertension, or obstructive sleep apnea to support severe obesity and laparoscopic sleeve gastrectomy. On sleep study, the patient was found to have disordered breathing without evidence of sleep apnea.
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 Sleeve Gastrectomy, 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