Tricare denied me - AGAIN!!

[AZArmyWife36 0]

Hello!

I'm soooo bummed out right now! Tricare didn't even take a look at it. It was submitted yesterday and denied today. Anyone have some appeal letters? Any help is greatly appreciated.

Thanks!

One sad girl :scared2:

[lauragshsu 6]

Did they say why you were denied? What is your height/weight/BMI? Any comorbidities? I'm only asking because my surgeon said tricare is one of the easiest to get approval from if you fall into their criteria.

[AZArmyWife36 0]

Hi! I do not know why I was denied. I just checked Triwest and it said not approved. I think it's because I'm not 100 lbs overweight. I do have hypertension. I called the doc's office and they don't have anything as of yet. Sucks! I'm totally bummed out! I'm planning on appealing once I find out what the reason of denial.

[spoiltmom 44]

Wow that really was fast. Maybe it was denied b/c there was some paperwork missing and not due to your weight.

[AZArmyWife36 0]

Spoiltmom, I hope it's something else! Wish me luck!

[eadreel 0]

You could try to get it all done in house at a base hospital, that way you don't have to get tricare's approval.

I know that in my case my PCM required me to have six months of diet and exercise logs in my medical files for easier Tricare approval. I had to see the nutritionist at the Health and Wellness Center every couple of weeks and also see the person in charge of exercise stuff. The nut would take a week out of my food journal in put it in my medical file along with my weight and what I was doing for exercise.

I do know that for Tricare to approve you have to have at least two months of documented food logs and exercise logs, plus be 200% over the high end of the Met life table's ideal weight or over a certain BMI PLUS two co-morbidities. AND you have to go with a surgeon and a hospital who takes Tricare.

I started my process Nov 03, 2009 and I JUST finished my preop blood work, psych eval, EKG and ultra sound and am seeing the surgeon for the second time the end of this week. My stuff hasn't even gotten to getting approval for surgery yet.

If you have done everything by the book, then call tricare and ask them why you weren't approved. I heard (hear say, rumors, baseless accusations) that sometimes they deny the first time out of hand then if it comes across again they actually look at the file.

The big deal is you have to have TWO of the co-morbidities that are listed from tricare. The two listed on file for me are diabetes and high cholesterol uncontrolled by meds, diet and exercise. Plus I have an 11 year military medical record showing how I have lost and gained the same 30-50 pounds over and over again.

Remember you gotta fight for yourself when you have Tricare.

[Mimilou2004 13]

Eadreel you have put out quite a bit of erroneous information about Tricare standards.

Mimi

[eadreel 0]

Mimi,

You are probably right considering the 8 months of jumping through hoops I had to do for my PCM on base. My doc has done right by me by giving me the best possible chance that I will get approval. It is true that the "official" regulation is 100 pounds over healthy weight for height and bone structure plus one comorbidity OR 200% over ideal weight for height and bone structure OR having a take down done. That is exactly what the requirements ARE, BUT, to get the very best results for approval the first time from Tricare my doc had me do it the way she did.

And Tricare Prime members have to use surgeon and hospital off her provider list or she can be stuck with the whole bill. And if a Tricare Prime member doesn't get prior authorization, but they use approved surgeon and hospital they may have to pay a copay or the whole amount.

The way Tricare reads is that all services for Prime members has to be gotten though a Military Treatment Facility unless there is NOT an MTF or the specialists in her MTF.

I was just sharing what I have been required to do by my PCM on base because she KNEW that if she put in the referral request back in November without the proper medical documentation of some kind of weight loss effort it would be denied out of hand by Tricare.

Tricare is still run by people. And people don't always follow the rules. And people make mistakes.

[lauragshsu 6]

One thing: not every military base has a hospital. At the one we're at now, it's a basic clinic and anything outside of the basic clinic abilities is referred off base.

Another thing is I don't know where you got your info on Tricare standards for surgery. I was not 200% overweight. I didn't have to follow a X-month diet. I didn't have to have a consult with a base nutritionist. I didn't need any proof of previous weight loss attempts. I didn't need to be 200% overweight or have two comorbidities. I was 144lbs overweight and had PCOS I'm thinking they considered that a comorbidity).

I started my process November 25 by going to my PCM for a referral. I had surgery March 15. I would have had surgery about 6 weeks sooner if they (Tricare) didn't keep referring me to psychologist who were out of practice, didn't do psych evals or were dead. They submitted the paperwork and I was approved within 48hrs.

[eadreel 0]

So basically I got a crappy PCM who decided that I had to meet her psycho requirements and I could have gotten surgery 6 or 7 MONTHS ago.

I hate the military doctors sometimes.

I have PCOS too, so I guess my crazy doc decided I had to go through a seven month diet and exercise eval to make me feel like an incompetent idiot with everyone looking at me like a liar because I was eating 1500 cals a day or less and expending about 3500 calories a day and I wasn't losing weight like the nut math says.

I wish officers would stop playing God sometimes.

[lauragshsu 6]

So basically I got a crappy PCM who decided that I had to meet her psycho requirements and I could have gotten surgery 6 or 7 MONTHS ago.

I hate the military doctors sometimes.

I have PCOS too, so I guess my crazy doc decided I had to go through a seven month diet and exercise eval to make me feel like an incompetent idiot with everyone looking at me like a liar because I was eating 1500 cals a day or less and expending about 3500 calories a day and I wasn't losing weight like the nut math says.

I wish officers would stop playing God sometimes.

I hate military doctors. Before being diagnosed with PCOS, I went to several base doctors (when we were stationed overseas). One told me I was making it up when I told him my period was ever 90-100 days. One said I was just too fat to have kids. Another told me to put down the bon bons and get off my ass (even though I was doing weight watchers and working out 6 days a week). One finally said "yeah you probably do have a fertility problem, but we have so many women already pregnant we're not going to help you.

So yeah, I hate military doctors.

[NoDonuts! 0]

Wow, I got a referral from base doc to see a bariatric doctor, got an appointment, approved the next day and my surgery was scheduled 2 weeks later. My Bmi was 42

[eadreel 0]

When I saw my doc in November I weighed 271 pounds with a BMI of 46. I had already lost some weight.

Back in November my doc said to me that I would have to prove to her that I couldn't lose weight before she would refer me. So over the next seven months she watched me as I struggled to lose 23 pounds. The nut math said I should have lost 70-80 pounds in that time.

Must have been because she is on thin ice for failing PT tests.

Needless to say I am at a very small base.

I cried last night because I finally got that I didn't have to wait 9+ months for surgery. I could be nearly at my goal weight by now if I had gotten the referral back then.

Then at month four when my H got orders for the sandbox she said that she couldn't in good conscience have me go through major surgery with no help at home. So it was another couple of months and two weeks before he was supposed to leave that he found out his job slot had been dropped from the list, so he wasn't going after all, then another month to get an appointment on base, then another month to get an appt with the surgeon and another month to get the appointments for pre op consultation.

I got screwed

[lauragshsu 6]

eadreel, you really did get screwed. I would bring up this Dr's actions to the HR or patient advocacy group. It's not her right to tell you if you can have a surgery why your DH is away. What if you had needed a major emergency surgery while he was away? Would she have insisted you wait until he came back? Lapband is a fairly minor surgery in the sense of size and recovery time. I would definitely go to patient advocacy.

To the original poster: call your surgeon and see if they can tell you why insurance denied it. You've done your end by submitting to testing, classes, evals, etc. It's their turn to work for you. They should know why it was denied.

Edited July 31, 2010 by lauragshsu

[Amaris 0]

I can't speak to anyone else's experience with TriCare, only my own. We have TriCare Reserve Select (Hubby is in the National Guard), and I was approved within 24 hours of submittal. My BMI is in the 50s and I have several co-morbidities. I didn't have to jump through a lot of hoops -- no weight history, no supervised diet.

I have heard that TriCare is one of the easiest for approval if you meet the guidelines. Call and see what the deal is. As someone else suggested, it may be a paperwork issue.

PS Thanks to all the military personnel for their service -- and to the families for their sacrifices.