Appeal Questions Can Anyone Help?

Hi Everyone, It's me again. I'm still trying to get all this appeal crap in order. I called Med Mutual today to see if they are ever going to send the info to me that I had requested. I ended up speaking with a woman named Cathy who I had to become very agitated with, but in the end, she emailed the appeals coordinator to tell her what the guidelines state in my policy & to also ask if they are processing my request...not that I think this will change anything but hey, it can't hurt. My question to those who have had to go through the appeals, did your surgeon assist you in the appeal process at all? The problem with me is that my PCP closed up shop so I no longer have her to assist me. I sent 2 emails to my surgeons office asking if he would write a letter on my behalf addressing the reasons for denial. I thought with his expertise & the fact that he may have access to certain info that I cannot come readily come accross, he may be able to write a wonderful letter....still haven't heard from the office yet. Second, there was a lady that was on the OH site & I looked over her appeal letter to her husband's work (they were self-funded too). She mentioned that she included in her documentation the NHLBI consenses statement from 2000 which apparently has to do with the NIH amended their clinical guidelines. These new guidelines deleted the six-month dietary requirement for the severly obese. I looked all over the internet (google search) but could not find this, or any other document that may help. I emailed her but to date, she hasn't responded. Can anyone help me out with this???? Thanks, Jen

Hi Jen Please do urself a favor. To back up ur case please file a complaint to { If u are in Ohio} to www.ohioinsurance.gov They are there to investicate into insurrance claims that has been decline. PLEASE go to this web site and file ur complaint first before the second appeal..... They can really help you if you have a case. With the state involved they will give you a case number and they will contact the insurance company for investication. once you recieved a case number provide to the state of comobilities and records from ur PCP for reason why you should be covered. Please use the state to fight this and it may wake up the goveriment to seriously look at obesity as a diease...... Please do this it may take alittle time but the faster you can get info sent into ur case with the state they may get coverage for you sooner. Don't fight this alone. I Care Daniel

Hi Daniel, I am not sure that the state Dept of Insurance can help in my situation because I had contacted them before I submitted my request for surgery. I am part of a self-funded group and I think this out of the scope of what the dept. of insurance can help with. When I tried to ask them questions, I was directed to the department of labor (I believe) because they have no control over self-funded groups...I will check it out though. I wouldn't mind a bit to complain about the stall tactics & fraud that I believe Medical Mutual is now participating in if it will help. If I am ever able to have the surgery, it will be with Dr. Maguire out of Kettering, Ohio. Jen

File ur case on line to the state so they have it in writting or send them a certified letter. Get them involved. also get the Dept. of labor involved. Do you pay for insurance coverage, if so the ODI should get involved. Also Please read my other post on obesityhelp.com

Jen who is ur surgeon

Hi Jen, Is this your first appeal? I, too, am appealing a recent denial, and I am also jumping thru those same hoops you are with MMOH. What pains they are! This is my first appeal so I'm wondering if I should try the ohio dept of ins as well...??? Thanks for any help, anyone... Pamela B.

Jen, here is the link to the 1991 NIH Concensus Statement. I don't think the NIH statement ever included any dietary requirements as a prerequisite for WLS. I think you might have sent me an e-mail - I did get my husband's surgery approved even though there was a BMI of 40 or over restriction, and he was about 38.2, and our plan is self funded. http://consensus.nih.gov/cons/084/084_statement.htm I will see if I can find anything more recent. Sue