Got Med Mutual's Letter & it is a Crock!!!!!!!!!!!!!!!!

I am so livid right now that I can't even see straight. First off the reviewer who made the decision has the following qualifications: Medical doctor board certified in Surgery So does this mean he may not even have any experience in bariatric surgery? The letter went on to blad AGAIN about the fact that I had not met the medical necessity due to my BMI falling below 40 & also that I did not have documented failure of physician supervised diet, non- surgical methods of weight reduction.....this crap set me off because my policy NEVER stated that the physician supervised diet was a requirement! I called Med Mutual & somehow got a person who gave me the # to Diane Tonkin-Collins who signed off on this letter & is listed as the appeals coordinator & this is what she had to say: First off, it's not a requirement that this doctor be in the Bariatric field just something close to it. So, what the hell can be close? Either you are in the field & can make experienced judgements or your not. She said that I can request info on him on what exactly his specialty is which I certainly will do!!! If they are going to send it to an independent person, it seems only fitting that it should be someone who sepcializes in that field!!!!!!!!! Next, I said to her that my policy does not state that a supervised diet is a requirement, & she proceeded to tell me that it is Medical Mutual's corporate policy. Well if that is the case, why the hell don't they just say this is a requirement in our benefit plans!!!! so it is a moot issue regardng the Atkins, Weigh****chers & all the other crap that I have wasted time & money on!!!!!!!!! Not to mention that they won't even look at my trial on the prescription diet pills because I only tried it for a month........that's because it was another $50 that was wasted because I didn't loose 1 pound!!!!!!!!!!!!!! I am sorry to rant but I really feel past frustrated with all of this!!!

In the letter does it say who to aske for to receive the scientific evidence. I would definitely challenge the corporate policy thing. If it isn't in your handbook you can't be expected to know. I would even threaten them with Walter Lindstrom if necessary. He is at Obesitylaw.com

Hi Jack, I have to send/fax a written request to the appeals department to obtain any info used & to find out what this doctor specializes in. My situation is different than others who have Med Mutual & I think that they are mishandling my claim. First, I am part of a group that is self-insured. We MAKE UP OUR OWN GUIDELINES, we DO NOT USE MED MUTUAL'S. So when she is saying that my self-insured group follows the guidelines that are set forth by Med Mutual she is wrong. I agree absolutely with you that if it isn't in the handbook, they shouldn't be allowed to use it! I think I am going to send a letter in regards to this to the Dept of Insurance (not that I think it will do any good). I unfortunately cannot obtain a lawyer because we are self-insured but I am trying to feel out the process to see if I should appeal to our board of directors rather than Med Mutual again. I am so scared of this though for 2 reasons. First, because I would more than likely have to appear in person & second, because it would be the final answer & I just don't know what I would do if the answer was no. Wishe me luck & I will keep you guys posted! Thanks for your support! Jen P.S. Know of any PCPs that I could go to that would take me on as a patient and aid me in pursuing this? My PCP decided to leave her practice in May & I cannot seem to find anyone in my area that is very familiar or receptive to the idea.

Is it a job in jeopardy issue that knocks out the lawyer. I would go to the Board even if you have to appear in front of them. They are screwing you and don't stand for it. I would also ask them to provide the scientific basis. Part of the problem is the lack of a PCP. I don't know any in your area because I don't know what area you are in. Hey we do have a local support group wlsbutterflynetwork that might be able to help if anyone cannot help here. RobinW is a member of the group

We are self-funded so the rules are different in terms of obtaining a lawyer....or so I am told, but come to think of it, I never actually asked Lindstrom if he could help.... You are right, Med Mutual is screwing me which is why I may have luck with the board......I'm just scared. I live in Steubenville, Ohio (still selling my house in Coumbus) so I would be willing to travel to columbus, Wheeling, Pittsburgh, if it would help. Yes, when my PCP said that she was closing her practice, I was a bit upset that she didn't tell me a few months back so that I could find another doctor who would be with me in the long haul....nothing ever comes easy for me. Jen

Jen, I wanted to tell you that Med Mutual also denied me in March, because i also didnt have and supervised weight loss attempts, although i had many others... my plan is also self funded and i have hired a lawyer Gary Visco..obesitylawyers.com... he is great he is in the process of writing my appeal..he is hopeful and so am I...I know its frustrating to deal with Med Mutual only for them to tell you they have undisclosed requirements but hang in there and I would check into an attorney he was able to help me eventhough we are self funded. Rachel

Hi Rachel, How great we have the option of hiring an attorney even though we are self-funded, I thought that eliminated that possibility. Is he expensive? I am not sure if I can handle that big of a expense right now, but hey, I am willing to look into anything. Jen

he has two options one is $495 and the other is $800..it includes everything..I went with the first option he writes a 40 page appeal letter and calls the insurance company for you. Its a frustrating process i hope everything works out for you!

Thank you so much for the info, I am absolutely going to look into this. I feared that it would be much more expensive than that, even though I feel that its still a big chunk of money to spend for something that I already feel a qualify for! I hope everything works out for you too! Jen

I completely understand your frustration!!! My Doctor faxed all my paperwork to Medical Mutual May 7th. On May 20th they state they did not get my non-surgical weightloss attempts. I filled that question out 3 times at the Doctors office. My doctor faxed the form again to them May 21st. Medical Mutual did not review my case again till June 15th. On June 18th they said that the information sent was still not enough so they denied my claim. I went to my doctors and they did letters for me stating my weight, bmi, health problems etc. They stated it would benefit my health and that they recommend me for surgery. I am still getting my appeal together. One of my friends also has Medical Mutual and she was denied the first time, then it got approved. She even had to send in pictures of herself!!!