One of the reasons patients and providers should be optimistic fighting denials is because in the vast majority of circumstances the final decision-maker is going to be somebody completely separate from the insurance company. This fight entails making sure the IRO request is reviewed by someone who knows the territory from both a medical point of view (such as an experienced bariatric surgeon), but also someone who knows that they are not bound by the insurer’s medical criteria! Rather, they should use appropriate national and international standards along with their own training and experience as guides for the decision.
This third takeaway bears greater emphasis: the independent, external review process is never bound by the insurer’s medical criteria which is why it is critical to submit medically-appropriate cases for authorization and why it is critical to appeal any denial based on inappropriate criteria.
We are mindful of the discrepancies between payer medical policy and the guidelines or care standards set by specialty medical societies like the American Society For Metabolic and Bariatric Surgery (ASMBS). Those recognized standards are what should be used by insurers, but that hardly ever happens. This means patients needing surgery have the option of walking away from a denial or tenaciously fighting it. We know the fight must happen, even when it is nearly certain the insurer will refuse to change its mind. Knowing we are setting up the appeal to ultimately get a decision from an independent, external physician reviewer governs how the case is handled right at the beginning, starting with the surgeon’s office “who gets it right.”