Minor updates on CA Reconstructive Surgery w/o Medical Necessity

A second class action suit against a California insurance company (Blue Cross) has been filed.  If you have been denied for reconstructive surgery post bariatric surgery for "no medical necessity," with ANY insurance company doing business in CA, please contact either me or the lawyer, Rob Gianelli (Rob.Gianelli AT gmlawyers DOT com; 213-489-1600) to either join one of the law suits or to get another one started. Another minor victory: although my insurance company has refused to comply with the order of the DMHC, which ordered Heath Net to preauthorize all of my reconstructive procedures, that case was filed as a grievance and did not go through Independent Medical Review.  The DMHC has met with its Independent Medical Reviewers and explained the CA statute which mandates coverage of reconstructive surgery without a requirement for having medical necessity for the procedures, and the first case has been posted on the DMHC website reporting the use of the PROPER standards.   Although this case was not a bariatric patient (a 52 year old man with a receeding jaw), the reviewers decision shows that the PROPER standards were used -- the decision quotes the statutory language and provides some hope that requests for reconstructive surgery post massive weight loss will be treated the same way.   While as I said, my case was filed as a grievance rather than a request for IMR, I have been told that insurance companies NEVER refuse to comply with a BINDING IMR decision.  So let's see how that goes when someone puts their post-bariatric reconstructive surgery appeal in using that language!  (I have been invited to put my case through the process, but it might mess up the class action suit, because so far, I am the only identified plaintiff, but the judge in the case ordered discovery on May 16th, so there may be a backup plaintiff soon.) Here is the decision, with the statutory language highlighted: A 52-year-old male enrollee has requested a genioplasty procedure for the treatment of his Class II malocclusion with an anterior open bite. Findings: The physician reviewer found that the patient has a maxillofacial skeletal deformity, specifically mandibular hypoplasia. These types of deformities may be apparent at birth or may manifest during subsequent growth and development creating functional, degenerative, cosmetic and/or psychological problems. Given the degree of this patient’s deformity, his mandibular hypoplasia/microgenia did constitute an abnormal body structure which was caused by a congenital and/or developmental abnormality. The advancement genioplasty was performed to create a normal appearance to the extent possible and improved the function of the mentalis muscle and lower lip. It did offer more than a minimal improvement in the patient’s appearance. The surgery was medically reasonable and appropriate.  According to the CA statute, reconstructive surgery is mandated when: 1) There is an abnormal structure of the body 2) Caused by ... a disease [or congenital or developmental abnormality, or surgery, or injury] 3) For which reconstructive surgery can [improve function OR] improve appearance to the extent possible 4) And wherein the improvement in appearance is more than minimal. Note that there is NO mention of medical necessity!  (Although it is interesting that the reviewer had to (reflexively?) add a nod to the procedure being "medically reasonable.")