MMO Denied My Appeal Any Suggestions?

Hi Everyone, I am just shocked that an independent review person looked at everything that I provided to them yet they still upheld the denial. My original request was denied due to 2 factors. The first was because my BMI fell below the 40 mark twice in the last 5 years. I have a clause in my policy that states individual consideration will be given to those who cannot consistently stay below the 40 mark so I thought I had that part made. The second part of the denial stated that there was insufficient documented evidence of non-surgical attempts at weight reduction. Unfortunately, I never discussed the different diets that I was trying with my doctor. I had in my chart that I was trying to diet & excersise but nothing in the way of saying that I tried Atkins Weigh****chers & all that jazz. So, I took about a month after receiving the first denial & gathered as much proof as I could about the diets that I tried. I obtained cancelled checks to Weigh****chers, a gym & GNC, credit statements for products that I had purchased, copies of books (Atkins & Dr. Phil) & copies of video tapes that I have used. I thought this would be more than enough proof that I was doing something not to mention the fact that my weight fluctuations was a clear indication that I doing something to try & lose the weight. In addition, I sent a 4 page letter that I had written, another letter from my PCP & physician notes from my OB/GYN & yet I am being told by MMO that the denial was upheld. The girl that I spoke to, was a real *B* so I couldn't find out what they based the decision on or even when I can expect the letter. Anyways, I don't know how to proceed from here. I know that I have the option of a 2nd level appeal but what more could I possibly say that would make them change their minds? What else do I submit that I haven't already done? Thank you to anyone who can offer any guidance, Jen

I'm sorry that you lost this appeal. I would really try again. Look on this site for sample appeal letters. Look at the letter I wrote to MMO and I got approved the first time. My BMI went under 2 times also, but I showed them that in the past 7 years I had only KEEP OFF a TOTAL of 7lb. Also talk to your benefits person your company can go to bat for you also and over ride anything they want. Keep us posted & GOOD LUCK, Robin W 218/135.5/115

Hi Robin, Thanks so much for replying. I did look at your profile when I was working on my appeal letter. I used the same way you did, outlining the diet attempts, dates, pounds lost/gained, but to no avail. They just won't budge on the fact that I haven't had a physician supervised diet. I recently posted a new message in regards to the letter I received & the person that I spoke to at Med Mutual. I really, really think that they are mishandling my situation because they do not make the guidelines for my policy, we are a self-funded group who has developed their own guidelines. Well, I'm going to keep fighting, its not like I am losing out on anything by doing so. Jen P.S. You look absolutely wonderful & have done a fantastic job!!!!!!!!!!!

jen-i am just re-reading ---when did they start asking for a dr supervised diet????? i didn't have to have that...... i understand that you are self pay and that it is diff --and that some policies have caps of 10,000 etc---but this is a new one for med mutual.....sorry- just thinking out loud!

Hi There, That's what I wanted to know because I know that my policy says nothing about a physician supervised diet. According to the member appeals coordinator, its part of Med Mutals corporate policy....doesn't seem legit does it?

jen.i'm sorry you were denied again- the second appeal does not give as much time as the first - so! once you get your letter do not waste any time... i am sorry that i don't have specific suggestions this morning- up too early i guess....do you have any co morbidities? sleep apnea etc? is there a strong family history of any ? def go to your benefits person and ask for help but don't waste time waiting if that is your only plan..... whatever you do- fight the good fight!

Hi There, Thanks for replying. I got my letter in the mail today, it was crap. I have 60 days to appeal now instead of 90 but I just don't know what else to do or say. I do have a few co-morbidities which were adressed in not only my PCPs letter, but in my medical records as well. It's been suggested that I have a sleep study done, but my surgeon's office said to hold off on that because if I have the surgery, it will most likely be eliminated. No strong family history of anything other than diabetes. I am going to continue to fight until I can't fight anymore! Jen

I agree fight fight fight. Also what one person asked for was the all the scientific evidence behind the denial n the next thing you know they got approved.

Hi Jen! So sorry to hear of your denial-but I do understand as I am going through the same thing right now with MMOHIO. I had my first denial 2 weeks ago and am now trying to get submitted all of the info. they are requiring! It seems that my PCP's office and LA WT. LOSS centers are not very cooperative. I guess if their lives were in danger, they would move alittle faster!!! My co-morbidities are: type 2 diabetes(with oral meds and 4 insulin inj. a day), high blood pressure, high cholest., severe sleep apnea and scleroderma(autoimmune disorder) and yet I was denied the surgery also. Go figure! I have tried every diet in the world twice and yet don't have documentation for them all so I guess they don't count! But I will be d____'d if I will give up and let the insurance co. win! It's not their life that is at stake,but mine! So, please hang in there and don't give up! Jan

Hi Jan, I am so sorry you are in the same boat, I know exactly how you feel right now. I am not going to give up either until there are no more appeals left. I just don't know what else to say in this 2nd level appeal that they don't have already......... With all of you co-morbidities, I cannot imagine how they have denied you, it's just not fair!!!! That was the first thing that lady asked me about was if I suffered from any. When I began to tell her that I had elevated sugar levels, possible aleep apnea, elevated blood pressure, she asked if I was on any meds....my response was (flatly) not yet but is that what this company is going to force on me, which in the end will only cost more money & lead to more complications? Well good luck to you & let's keep in touch & let eachother know how the process is going! Jen