DeterminedWifey

I was denied by Tricare Prime west region (triwest) for gastric bypass. I am OVER 100 lbs overweight and a bmi of 42 with NO comorbidities. I plan on appealing but what can be my fighting arguement since i have no documented health problems, no diabetes no hbp etc.. ? I do not want to give up, do i have to finally get to the point of becoming diabetic for them to approve me? Iam disappointed, but if anyone can give me any pointers or tips about how to make my appeal It will GREATLY be appreciated. Also, does triwest automatically go by the medium body frame on the metlife chart? Or can my surgeon simply state iam small framed, if so i meet the 200% over requirement...(small framed)

well i decided on the bypass because i liked the idea of a "permanent" tool to help with the weight loss, and the fact i wouldnt be comfortable with something foreign in my body and im not going to lie, the drastic weight loss is appealing as well. So what kind of problems did your family members encounter with the gastric bypass if you dont mind me asking?

My referral was also sent through the chief of surgery first but it really didnt take long to get the approval. I did have to follow up because my pcm "forgot" to send in the request. And yes they are referring people off post (thankfully lol) They assigned me to a surgeon but i had already done my research prior so i changed it to dr.applebaum. This coming week will be busy, they've scheduled me for psych eval on monday, nutrition on wednesday and surgery consult on thursday!! Also are you getting the lapband? I decided on the gastric bypass, even though this is a lapband forum i recieved more helpful info on here than any other site! Let me know how it goes!!

Rubytuesday-- I personally think you have good chances of getting approved. As long as you meet their requirements which is 100 pounds overweight with one of their comorbidities (high bp)you shouldnt have a problem. Just make sure it is all documented and its all sent in, that way you wont have to appeal which can take up to 90 days, thankfully my appeal only took 30 days to be approved. Also, have you registered online at triwest? I did that right after my pcm sent in my first referall for the surgeon consult and it was approved within 2 days. Goodluck!! Feel free to contact me anytime if you have questions!

Well i just checked my status on the triwest website and ive been approved!! I didnt want to post until i recieved the actual letter in the mail and it too says the initial denial has been overturned!! I'm so thankful it didnt take all 90 days, Thank you EVERYONE for your info and suggestions!!

Well it turns out the reason I was denied was because I had none of the co morbidities that are required for triwest to cover the surgery.. Simply put there are no gray areas in the approval process(ie; age requirement)- from what I was told. On a more recent note, turns out I have hypertension and have been put on meds. So I decided to appeal and am now waiting to hear back from triwest.. If it takes the entire 90 days ill have a "yes" or "no" by october.

Thank you for a speedy response! I just spoke to tricare and they said the reason for denial was because it was not medically necessary.. I plan on writing a letter and sending pictures from my childhood, any other ideas?