external appeal

I was wondering if anyone in OH has done an external appeal and has been successful. Can anyone give me any information I what I need to do for this process? Thank you Cheryl

Cheryl, An external apppeal is requested when Med Mutual has denied your procedure for medical necessity and you disagree. When you request an external appeal, an independent review organization reviews your appeal. I would submit all comorbid conditions, all medications needed for those conditions, and then a very detailed diet history along with the details from your dr office of the 6 month physican supervised diet. I would also send the psych eval also since this agency is reviewing this for the first time. I sent copies of my medications receipts, my cpap receipts, my dr office notes on the diet and also my dietician's notes. I saw the dietician also to cover my bases. Send everything that shows you need this surgery. Go to the Medical Mutual web site. Click on Publications. Click on Manuals. Click on Hospital Reference Manual. Scroll down to the bottom of the page and click on Hospital Reference Manual again to open the manual. Open the manual and scroll down to Appeals. It will explain it all to you. Hope this helps Sandy

Sandy, Thank you so much for your help. I am going to do as you suggested, luckily my PCP is really good at writing letters for me. I wasn't sure what to send to the review thank you again for sharing. Cheryl

Hi Cheryl I agree with Sandy. Remember - when asking for an external review, they will rereview your file first. This is when I was approved - they knew they would loose. I used a letter from here (OH resources) as a guide for my letter. I also had my psycholgist write an update letter and submitted copied of my doctor visits - I had started going monthly. Good Luck Sharyn

Sharyn, Could you please tell me where you found the letter to use as a guide, I would really appreciate it. Thank you Cheryl

http://obesityhelp.com/content/letterofmedicalnecessity.html If link doesn't work, cut&paste to the address line. Or email me and I'll get you a copy of mine. Paula