Treatment class · subcategory · California
Bariatric Surgery denials at external review
When a California health plan denied care in the bariatric surgery class and the enrollee took it to Independent Medical Review, this is what independent physician reviewers decided.
63.4%
- Overturned
- 26 of 41
- Era
- 2021-2025
- Jurisdiction
- California DMHC IMR
- Published class
- Bariatric Surgery
- Median days to decision
- 42
- All years
- 54.9% of 82
Authorities named in this class
computed- National Institutes of Health—2
- American College of Cardiology—1
- American Heart Association—1
- FDA—1
A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.
By condition
computed- Overturned — the reviewer did not sustain the denial
- Upheld — the reviewer sustained the denial
- Endocrine & metabolic62.5%32
- Digestive & GI—3
- Post-surgical complications—3
- Orthopedic & musculoskeletal—2
- Cardiac & circulatory—1
The specific conditions inside this class
below n=30, no rate is claimed- Obesity61.3%31
- GERD/Reflux Disease—3
- Other—3
- Diabetes—1
- Lymphedema—1
- Osteoarthritis—1
- Osteoporosis—1
By review type
computed- Medical Necessity56.7%30
- Experimental/Investigational—11
Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.
Every figure on this page is conditional on a denial having reached external review. Fewer than 1% of denials are appealed internally at all, so this describes denials that were fought to the end — not denials in general — and it describes California only. Who this does not cover.
Free help, first: the California DMHC Help Center files your Independent Medical Review at no cost — 1-888-466-2219, dmhc.ca.gov.