Tricare Prime has denied me

[JamieNP 20]

Wow....I would call today and find out the reason for the denial..I know people with your numbers that have been approved. Sometimes it is the Doctor's office that causes the denial (ie, they don't have everything in, they don't use the right codes, they don't do the right tests). My doctor is former military and does a lot of tricare patients. There are many tests that he does that some of you have not had to go through. They acted shocked when I told them I was not sure Tricare covered me...they said "tricare approves everyone". "With your comorbidities you will have no problem". They told me Tricare requires the EKG, EGD, sleep study and PSY exam. My numbers are lower than yours, but my comorbids are high blood pressure and sleep apnea (I am on cpap).

Appeal appeal appeal!!

[armywife4life 0]

keep trying, you should qualify

[cobrien78 0]

Seeing everyone get denied by tricare makes me worried I won't get approved. I am more than 100lbs overweight and I have PCOS, high cholesterol, high blood pressure. I haven't been diagnosed with sleep apnea but haven't had a sleep study done.

Someone mentioned earlier that tricare doesn't count PCOS, I think they do and was wondering where they heard this from?

I definitely plan to appeal a denial, I am NOT taking NO for an answer cause with my family medical history I'll lucky if I make it to 40 with the road I am on. I'm not even exaggerating.

[azairforcewife 1]

so i called today and they said they just but not approved on the website until it as reveiwed.i told them they should but in being processed or something i was up all night upset for nothing !!

[JamieNP 20]

OMG! Why did they have to do that! They should have put "pending". Keep us updated!!

[katinafer 0]

I know that cholecystitis counts as a comorbidity but was wondering if it still counts if you've had your gallbladder removed? I suffered from acute cholecystitis and my gallbladder was overrun with stones. I had my gallbladder removed this March.

I finally have my appt. with my surgeon on the 6th of August and they have scheduled my surgery for 18th August (pending approval by Tricare Prime). I'm beginning to get nervous thinking that I've come this close and they'll deny me for some reason. FYI, i'm 5'2" 224lbs other than the cholecystitis, gestational diabetes that I had and bad knee and back problems I don't believe that I have any other comorbidities. I do however have a bad family history of obesity, diabetes and hypertension but am not sure if that really matters.

Thanks and good luck to all!!

[cobrien78 0]

Hey Katinafer I was wondering the same thing because I had mine out in October 07. The military dr. that gave me my referral (not my PCM) said it didn't count cause the removal of it resolved the issue. However, he didn't seem to know much about bariatric surgery so I'm not sure if that is true or not.

[AZArmyWife36 0]

denied:frown:i have tricare and the dr office sent everything in yesterday and today i went on the web site and it said denied. i am 236 and 5'4 and thats 100 pds overweight by the met life charts and i have thyroid and pre diabedic!!! im so bummrd im calling in the morning for a reason any body else have them change approval after calling ?

Hi! I'm so sorry they denied you. I immediately called in and found out that customer service could not give me the answer. I had to wait for the letter in the mail. I did send my appeal last week and as of now have not had any response. I'm keeping my fingers crossed. Make sure to appeal it. If mine does go through this time I'll let you know. Good Luck!

[aculberg 0]

Sounds like were all pretty much in the same boat here! Mine was submitted last Fri (the 25th) along with a fix for my hiatal hernia. Well, the hernia one is approved but the lapband still says "pending review"!! I got a letter today from Tricare saying they need more info from the docs office and only have 10 days to get that submitted, when the letter was faxed to them on Mon. So, here I am scrambling around to call the docs office (of course they dont answer) to see what all they still need. And I only have until Tues to get this all faxed back to Tricare!! UGH! They said they needed documentation of hypertension, even tho I'm on meds for it, and the list of meds I'm taking, plus lab work, etc. I had all the tests the surgeon requires and he found some scary stuff, the hernia, plus a non working gallbladder that will be removed at a later date, hopefully after the lapband. So, here I still sit and wait, until Monday, again, until I can contact the insurance coordinator, and get this all re-submitted!

AZArmyWife - what all did you put in your appeal? Any info would be great just in case!! Thanks so much...:cursing:

[azairforcewife 1]

so i clled tricare again today and i get a different answer everytime i call one will say they need more clinicals another will say the doctor did not send in the addtional info in fast enough when it had been just two days and the last one said i had to appeal any ideas? i'm soooo frusterated!!!!

[AZArmyWife36 0]

Sounds like were all pretty much in the same boat here! Mine was submitted last Fri (the 25th) along with a fix for my hiatal hernia. Well, the hernia one is approved but the lapband still says "pending review"!! I got a letter today from Tricare saying they need more info from the docs office and only have 10 days to get that submitted, when the letter was faxed to them on Mon. So, here I am scrambling around to call the docs office (of course they dont answer) to see what all they still need. And I only have until Tues to get this all faxed back to Tricare!! UGH! They said they needed documentation of hypertension, even tho I'm on meds for it, and the list of meds I'm taking, plus lab work, etc. I had all the tests the surgeon requires and he found some scary stuff, the hernia, plus a non working gallbladder that will be removed at a later date, hopefully after the lapband. So, here I still sit and wait, until Monday, again, until I can contact the insurance coordinator, and get this all re-submitted!

AZArmyWife - what all did you put in your appeal? Any info would be great just in case!! Thanks so much...:wink2:

Hi! I went ahead and did my appeal on my PCOS and Asthma. I talked about my childhood and having to grow up being overweight. I also included some editorials on why bariatric surgery is helpful in PCOS and Asthma. Also, talked about my parents and their ailments. I checked Triwest and it shows Pending Review. I'm keeping my fingers crossed that it will be approved. If you like I can email you some appeal letters that were sent to me. Just let me know. Best of luck!

[azairforcewife 1]

I would love some info on appeals for thyroid and diabeates i'm starting to do mine today.

[aculberg 0]

Hi! I went ahead and did my appeal on my PCOS and Asthma. I talked about my childhood and having to grow up being overweight. I also included some editorials on why bariatric surgery is helpful in PCOS and Asthma. Also, talked about my parents and their ailments. I checked Triwest and it shows Pending Review. I'm keeping my fingers crossed that it will be approved. If you like I can email you some appeal letters that were sent to me. Just let me know. Best of luck!

Any letters and ideas you have would be soo great! I'm wondering whats going on with Tricare, at first I heard it was soo easy to get approved and now it seems like everyone is getting denied! I will pm you my email address. Thanks so much!

[Nena 0]

I was underweight too. So I just started eating sweets until I was at the right BMI and now I've been approved. It's sad, I had to gain weight to lose weight.

[JamieNP 20]

Doesn't it seem like most of the people that are getting denied end up getting approved?

I am getting so nervous..I cant stand it!