Medical Mutual Denial

I have Super Med Plus. I am having a terrible time, currently in appeals. I went to a Physician Supervised Weight Loss Clinic for 16 months 1/00 to 5/01 and was told this documentation is not sufficient. I did lose weight 49 pounds and at my last weigh in had only gained 5 pounds. How can they say Lack of Clinical Documentation by non-surgical methods? Anyone else having problems

Martha, I just wanted to let you know that I feel that same way about Medical Mutual. They tried to tell me that I needed more documentation. I provided them with more documentation and they still denied me. Be careful with your appeals. I was told from customer service at Medical Mutual that I could do three appeals, well that is not so. I could only do two appeals and the last one that I done, they sent out to one of their resources and they still denied me. I think that they should not be allowed to make the final decision when you have more than one doctor that says you need this surgery. Good Luck! Michelle

Well I called them today and let me tell you I have been a real pain in the a$$ to them. I have sent so many faxes, e-mails, daily calls, photos, angry letters until I have about had it. Three other women were approved with little to no problem. Have you thought about an attorney, Gary Viscio? Mine too has been forwarded to an outside source. Yes I do know there are only two appeals and the three is external. I weigh over 300 pounds and have been for nearly 9 years. The lowest I got when I lost that 49 pounds was 251. BMI still well over 40. Don't give up try again. Keep me posted

Martha, I also have called and drove them crazy and sent many faxes, but it did not do me any good. My BMI was 38-39 when I started this process with documented high blood pressure, sleep apnea, high cholestrol and they still would not budge. I know that having a BMI of 40 is one of the main requirements, but I have in writing from Medical Mutual that states it your BMI is 35 or above with co-morb. than you will be considered. I provided them with documentation of all of my co-morb. along with letters from each of my doctors stating that my weight was the main problem of why I had all these conditions. Still would not approve me. They just kept giving me different reasons. They said that all of my co-morb. are being controlled with medicine. I even told them how much it cost in medicine each month. But that did me no good. We are self-insured where I work. It is not like it was coming out of Medical Mutuals pocket. Michelle

Michelle, When you sent in your appeal did you have everything in order the way they wanted it and they still denied you?

i have med mutual-super med plus- they asked for 5 years of weight documentation- i got a copy from my pcp of 1 day in each year that i had been weighed in his office- where i didn't have pcp i used other docs- and they will accept one photgraph--must be the last 5 years not just any years- you must be very careful to document who you speak to and when and keep copies of anything you send them...as for the appeals- watch the time limits on them - my first was like 180 days and second was only i think 60 days....first was done by doc and second had to be by me.... their verbage is very specific- you have to understand what they are saying -and show them where they are twsiting it---and when you talk to customer service you have to ask the RIGHT questions!( and don't ask me what they are- i mean whatever you want to know you have to be sure to ask it properly-they won't give up any info!!!!) good luck to you!

If you are self insured your company's plan administrator may be able to overturn your denial. If not, you could contact the rep for your company at Medical Mutual. This is what I did. I always talked to the same person and I was able to get better information about what was needed specifically to have approval.

Jamie, I work for a county office and I already went to the county commissioners trying to get them to overturn Medical Mutual's decision and they would not overturn it. I personally don't think that they have the medical background to say yes or no. They are worried about costing the county more money, if they only knew how much money is wasted in the department that I work for in salaries. People come in for an hour a day and get paid for the whole day. I am the only one in my department that is hourly. I don't get by with stuff like that.

Oh goodness, Sorry to hear about your your cir****tances. I also have Medical Mutual, Super med plus, and I am awaiting yea or neah, also they list under MedBen as well. This is a gloomy outlook, now I dont know what to expect. Keep me updated as I will you Thanks Jackie

I also have med mutual. I was denied as well because of not enough non surgical weight loss attempts. i am in the appeal stage, but am not expecting much either. i have a bmi of almost 51 and have insulin diabetes, asthma, gerd, chronic back pain, and high blood pressure. i have been seing my pcp during the appeal stage, to document my weight and for "weight management" so if this one comes back denied, then ill appeal again. amazing that someone else can determine your life for you. Im 33 years old and without this surgery, i dont think ill live to see 40. good luck. email me if you want to talk. [email protected]