Ideas for tricare appeal

[azairforcewife 1]

I GOT MY DENIAL LETTER TWO DAYS AFTER THE DOCTOR SUMMITTED 93 PAGES OF INFO .I'M GOING TO APPEAL BECAUSE I'M 5'4' 236PDS AND HAVE THYROID AND DIABEITES SO I SHOULD HAVE MET THE CRITERIA ANY IDEAS ON WHAT I SHOULD BUT IN MY LETTER. ANYBODY HAVE ANY GOOD RESULTS WITH THEIR APPEALS?:teeth_smile:

[e60 0]

obesitylaw.com

[Long2BFree 12]

I'm not sure that thyroid problems qualifies as a co-morbility like diabeties does. Have you called Tricare to ask why they denied you?

[azairforcewife 1]

Isn't thyroid -hypothalamic disorder the same?

[Tuger 1]

Tricare uses the Metlife weight table when determining how much you should weigh but they also use your body frame size. First thing I would do is call your doctor and find out what frame size they said you were. Then look at the Metlife weight table for your height and frame size to determine if you are the 100 lbs overweight Tricare requires. For example, if you are a small frame and the Metlife table puts your weight at 109 - 121, then you will have to weigh at least 222 lbs for Tricare ( they use the high end of each frame size ).

I am battling this same thing with Tricare right now, however I weigh on the low end of my frame size with Thyroid, arthritis and sleep apena. The weight is not too big of an issue with me for if I am not very strict with my eating habits, I'll gain weight like crazy.

Hope this gives you a place to start.

[aculberg 0]

I GOT MY DENIAL LETTER TWO DAYS AFTER THE DOCTOR SUMMITTED 93 PAGES OF INFO .I'M GOING TO APPEAL BECAUSE I'M 5'4' 236PDS AND HAVE THYROID AND DIABEITES SO I SHOULD HAVE MET THE CRITERIA ANY IDEAS ON WHAT I SHOULD BUT IN MY LETTER. ANYBODY HAVE ANY GOOD RESULTS WITH THEIR APPEALS?:smile:

It looks like were having the same problem! I havent been denied yet, mine still says pending but I'm preparing myself for the worst. I too called Tricare and they said they needed more clinicals, that was Fri and my Doc's office was closed by then. I'm calling them first thing this morning to get them to fax whatever else they need! Tricare only gives them 10 days to get the info back to them or else they will deny it. I'm preparing myself for an appeal though. Your thyroid does fall under hypothalamic disorders, I believe. I looked it up. And diabetes definately does. Please let me know what you come up with for your appeal, because alot of our stats and co-morbids are the same. Good luck, let me know!

[JamieNP 20]

I got a booklet from my surgeon and there are examples of letters in there. I will try to write it out here

Dear (insurance Provider contact),

I am appealing your decision for denying my medically needed weight-loss surgery. My ht and wt are __ and __ and my BMI is __. As statistics show and as medical doctors, you must be aware that diet and exercise help, but as a long term resolution to permanent wt-loss only 5% of people succeed. I am well aware of the risks with this surgery, but I believe the risks of being morbidly obesity out weigh the risks of surgery.

I am _ years old and have been over-wt since I was _ years old. I have been on diets my whole life, having some success, but would always gain the wt back I lost, plus more. I will list the diets I have been on, but never kept any documentation because I could not have known at the time the insurance company would require it. Nor did I know that until this fairly new surgery even became an option for me, I would have to document wt loss before getting the surgery.

(list ALL diets, wt- loss products, programs used. If possible, use documentation.)

I have many co-morbid diseases, such as ___. (list meds also). You can also list family history related to obesity here.)

(discuss everything about how morbid obesity affects your life)

Sincerely, (your name)

[aculberg 0]

JWRN - Thanks so much for that! I see that youre getting your EGD today, good luck! I had that done, and turns out I have a hiatal hernia...I'm still waiting on my surgeon's insurance specialist to get back to me about the clinical info that Tricare still needs...but I'm preparing myself for a denial just in case. I'm not gonna stop fighting for this!

Thanks so much!! :smile:

[JamieNP 20]

Like I said, my surgeon and his office do not think I will be denied. BUT, just in case, I am getting my appeal letter ready!

[SuzanneG 1]

I was 5'4.5" and 225 and denied the first time through. I appealed and was approved.

I've shared my letters with anyone who asks and so far, based on those who kept in touch, they all got approved.

I would be happy to share my letters. Just PM me with your email address and I'll shoot them out to you.

[ceubanks 0]

Can you please share your letter with me. I was denied two days ago and I just do not know where to start

I was 5'4.5" and 225 and denied the first time through. I appealed and was approved.

I've shared my letters with anyone who asks and so far, based on those who kept in touch, they all got approved.

I would be happy to share my letters. Just PM me with your email address and I'll shoot them out to you.

[ceubanks 0]

please send me a copy of your appeal letter here is my email information ccccceubanks@yahoo.com

[azairforcewife 1]

i CAN POST MY APPEAL LETTER TOO!aFTER 2 APPEALS AND A FORMAL APPEAL I WAS FINALLY APPROVED .IT TOOK 6 MONTHS BUT IM SO EXCITED!! SUZANNE SENT ME HER LETTERS AND THEY REALLY HELPED!

[ceubanks 0]

I would really appreciate it. I am fighting for dear life and need the help

i CAN POST MY APPEAL LETTER TOO!aFTER 2 APPEALS AND A FORMAL APPEAL I WAS FINALLY APPROVED .IT TOOK 6 MONTHS BUT IM SO EXCITED!! SUZANNE SENT ME HER LETTERS AND THEY REALLY HELPED!

[El Diablo 1]

It looks like were having the same problem! I havent been denied yet, mine still says pending but I'm preparing myself for the worst. I too called Tricare and they said they needed more clinicals, that was Fri and my Doc's office was closed by then. I'm calling them first thing this morning to get them to fax whatever else they need! Tricare only gives them 10 days to get the info back to them or else they will deny it. I'm preparing myself for an appeal though. Your thyroid does fall under hypothalamic disorders, I believe. I looked it up. And diabetes definately does. Please let me know what you come up with for your appeal, because alot of our stats and co-morbids are the same. Good luck, let me know!

Mine was approved on day 10 but I did have to have the doc's office send "more clinicals" whatever that means. Seems like a common problem, why don't they just send everything the first time and save people having to appeal just because enough info wasn't sent in.