Medical Mutual Woes

Hi Everyone, I had posted this on the yahoo DS forum twice & received no response so I thought maybe that I could get more feedback here. I'm looking for those who have maybe run into the same situation as I have & what they did to get approved. I am also looking for any kind of suggestions or feedback. I was denied because of the following: The medical information provided does not meet the criteria for authorization of this procedure. We consider this procedure medically necessary for individuals who have a body mass index of 40 or greater over the last 5 years in spite of conservative weight loss interventions. Insufficient documented evidence of non-surgical attempts at weight reduction. Now, in the 5 years, I fell below the 40 mark twice (& it hasn't even been in the last 2 years) because I dieting & actually using a ephedra based product. Once all the info came out about this & people dying from using this product, I of course stopped. What happened? The weight came back on with avengence! I was only able to drop into the obese category so it wasn't like I became twiggy! My policy has a clause in it that states individual consideration will be given to those who cannot consistently stay below the 40 mark. As for the documentation, I do not have much in the way of documented evidence other than for the last 2 years, my pcp has in her notes, conversations that we have had & she did prescribe a diet pill. What I do have is cancelled checks & credit card statements for products that I bought & tried, including Weigh****chers & a payment to a gym. Has anyone else been in the same shoes with the same kind of documentation been approved? Any suggestions? Thanks to anyone who can help! Jennifer

HI, Post this to the main message board too and you will get more replies. PJ wfad or waiting for a date

I have MMO also. Here's a copy of the letter I wrote them along with everything the docs sent in. To: Medical Mutual of Ohio I'm Robin Wren, 41 years old. I'm 4'10" and weigh 211 pounds and have a BMI of 44 which puts me in the morbidly obese group. I have been overweight since the second grade. I have been on lots of diets and workout programs through my life. Here's a list of the more recent years. Year Program Start Weight End Weight Total Lost 1996 Medifast 215 169 46 1997-2000Programs Slim Fast Making the Connection-Oprah and Bob Green Weigh Down-A Christian based weight loss Richard Simmons, Deal-A-Meal, Richard Simmons work out tapes Other work out tapes, Mary Hart, Jane Fonda, Denise Austin, Kathy Smith 1997 196 1998 218 1999 217 2000 Xenical 218 185 33 2001 Metabolife 211 200 10 2002 Programs Ultra Slim Fast, Leslie Sansone tapes, Losing It On Line support group 2002 215 177 38 2003 211 In the past 7 years I have managed to keep off only 7 pounds from my highest weight of 218. My grand mother was obese, and my mother is also in the Morbidly Obese group. My mother is also an insulin dependent diabetic. I have developed arthritis in both of my hips with the left side being the worse. I am taking Celebrex for this. I suffer from depression that I believe is related in part to my being morbidly obese and many years of dieting and failing. I'm currently taking Fluoxetine 40mg once a day and Wellbutrin SR15mg once a day to treat my depression. I have difficulty performing many daily activities, and participating with my family and friends in recreational activities. For example it is very hard to walk around with my children at The Beach Water Park. They want me to go on the water rides with them but I don't even think about that. You have to climb up several flights of steps in order to get to the beginning of the water slide. I can not do this without stopping several times to catch my breath. I don't want this surgery in order to look great. I want this surgery in order to be healthy and to be able to move better. I want to be able to do things with my husband, children and friends. I want to be able to walk up a flight of steps without getting out of breath. I am very motivated. I am determined. I have the skills, the desire and tenacity to make the weight loss surgery a success. I know that bariatric surgery is a big decision, I've done a lot of research on it. I already belong to several weight loss surgery on line support groups. I have started attending local weight loss support meetings that are held either on a biweekly, monthly or on a bimonthly schedule. This is major surgery and a major life style change. Weight loss surgery is not an easy way out. I have struggled with being overweight for most of my life and I'm tired of struggling. I feel that is why I need Roux-en-Y and that is a medical necessity. You will find enclosed all the information Medical Mutual of Ohio requires. Diet history from my self for the past 5 years (this letter). Diet history letter from my primary care physician. Psychological evaluation. Specific information from the surgeon. Thank you for expediting my request and forwarding the authorization as soon as possible to the doctors office. Please contact me if there any other information you need. Sincerely, Robin N. Wren Goood Luck, Robin 11/17/03 218/147.5/115-120

Hi Robin, Thanks for the reply. I think my biggest hurdle is going to be the insufficient documentation for 5 years from the physician...is this something that you had? Thank You! Jennifer P.S. Someone emailed me on the main site & told me that by 1/1/05 Med Mutual will not be paying for this....have tragic & VERY SCARY!

jen--do you have documentation from ANY other doc--maybe ob/gyn or anything- that you visited during the last 5 years????where there would be a weight--i had to actually pay to get a copy of said ob/gyn visit for myself..... med mutual will accept a photo with your name and date on it--but i also had to send a copy of my driver's license in adddition to a family photo for the year that i was missing doc visits.....

Hi Margo, I had the 5 year weight history no problem....I even sent in 10 years so they could see that it has been a life long struggle not just something that happened for the last 5. What I don't have is progress notes that say I was on weigh****chers, Atkins & all that jazz. I do have credit card receipts & cancelled checks to validate this though.... This has all been just a pain in the you know where. I just hope that my appeal will go through.

oh yes!!! i know exactly where it is a pain and i sympathize!!!!!!!!! i did not have to submit proof of atkins ww's etc--i made a list of diets that i had been on and outcomes -if i had proof great but that wasn't the issue--they don't require diet stuff like some companies do-- wow--- keep plugging!

I gave supplied Med Mutual with a chart detailing the things that I had done, the dates that I did them & the amount that I lost...apparently this wasn't good enough for them...such pains in the rear, I just can't get a break!

Jen - I just was approved after being denied. The reason was the insufficiant data for medically supervised diets. I am diabetic so I had my endo write a letter - with a strong tone. This will be really long so email me direct at [email protected]. We can chat privately - might be able to help ya. Deb

I'm assuming that you're looking for approval for the DS. Are you sure MMOH covers the DS? I know Aetna and many other insurances don't cover the DS because of the long term affects of the severe malabsorption that comes with the DS. Did you send copies of you medical records showing the conversations with your PCP or did they just write a letter? If no records were sent, that may help. Do you still have your WW weigh in card? Aetna accepted that from me as proof of diet. Good Luck