Tricare Approval or Denial??

[Abbey M. 69]

thanks for the quick response. Oh im telling them im 5'3". the funny thing is when i got a copy from my demographics from the doctor it had me as 5'8"!!! I asked the nurse (who was SOOO helpful)...right.....if she would change it and she said she couldnt. so i called tricare and they said they dont see any of that information. the surgeon i am being referred to will submit the report with that information. so that was a relief. so i decided im gonna sqwat a little bit so im only 5'2" when they measure me. maybe some 10 pound ankle weights too....lol! we'll see what happens. my PCM was COMPLETELLY against me doing this so the fact that he even gave me a referral is amazing! that was a fight all in itself :-)

[talkalot1981 5]

Brooke- becareful with ankle weights. I was going to do that too, but realised I actually gained enough weight. My doc checked my ankles for swelling. So if you use the weights be sure to take them off right afterwards and hide them in your purse. LOL Just a heads up LOL Jennifer

[munger 0]

Brooke- becareful with ankle weights. I was going to do that too, but realised I actually gained enough weight. My doc checked my ankles for swelling. So if you use the weights be sure to take them off right afterwards and hide them in your purse. LOL Just a heads up LOL Jennifer

A friend of mine tried this - lead BB's in her bra! Nobody checks there!

[talkalot1981 5]

I got approved today!!!!! My surgery date is scheduled for July 28th. Jennifer

[munger 0]

Congrads! I hope you do well! I lost 15 pounds right off the bat - now I am at 1-2 pounds a week.

[Ready4a2ndChance 0]

I got approved today!!!!! My surgery date is scheduled for July 28th. Jennifer

That's awesome!!! Congratulations!!!

[tkee99516 1]

I also was originially denied by Triwest Prime due to the fact they stated I didn't meet the critieria of 100 lbs + 2 co-mobidities or over 200% my idea body weight using the Met Life Table.

My stats: Height: 5'3" and 227 lbs with no co-mob other than high cholesterol (doesn't count with Triwest).

The denial from Tricare was based on the fact the surgeon's office stated in their request for authorization letter that I was a MEDIUM BUILD (they did not measure my elbow). The Met Life Tables states for my height & Med Build to be in the range 121-135. So using the 200% method (the only one I could qualify for) I would have to weigh in at 242 plus.

So what I did was go back to my off base MD, had him measure my elbow, and found out I was a SMALL BUILD (at 2 1/8 inch). Having a small build, a woman, height of 5' 3", and weighing 226 PUT ME IN THE 111 - 124 LBS ideal weight bracket. Then I had this same MD write an appeal letter for me telling Triwest they had misinformation from the surgeons office regarding my frame (again, surgeon's office never did take a measurement & assumed I was a Medium frame). In the appeal letter we used the 200% (111 x 200 = 222 lbs) as my being overweight & requiring the surgery.

So Triwest took ALL 60 days (yes, they are little buggers, arent' they?!) and authorized approve for my lap band which will be scheduled for 8-25-09.

So folks - MEASURE your elbow. You just never know....:confused::blushing:

P.S. Here's a website for the elbow measurements (scroll all the way down) using the Met Life Table that Triwest uses:

MetLife Height-Weight Tables

[Ready4a2ndChance 0]

I just did the elbow measurement test, just as it said to do it and my elbow is seriously almost 4 1/2 inches.......the bones, I could clearly feel them, thats NUTS

[tkee99516 1]

That's why they advise you to go to your MD because a "A physician would use a caliper" per the directions.....

[Ready4a2ndChance 0]

well im glad i already meet the standard:rolleyes2:

[Ready4a2ndChance 0]

sorry didnt mean the eyerolling face meant smiley:smile2:

[Tina254 0]

Ok I'm just in tears right now because I think I'm approved, my doctor just put it in yesterday!!!

Ok so I have a question: My TriWest status says "Approved w/Modifications"...what does "Modifications" mean? Does it mean I'm approved but I need to modify something??

OMG...if I'm approved I'm going to scream, I'm so happy so see the word "approved", just need to figure out "modifications".

Edited July 2, 2009 by chrystinaw

[haroldrussi 0]

I had the same but in reading the details on the TRIWEST site I found my answers. Tricare will call you in a few days as well if you have not figured out what mods they recommended you can have them to clairify it. Good luck

[talkalot1981 5]

My approval said "Approved with modifivations" also. But that was an approval just to see the surgeon. Not for the surgery its self. I had one surgeon approved to see. He wanted me to pay out of pocket and when I conplained to Tricare they referred me to another surgeon who did not. So they had to modify my first approval. They might have approved your surgery, but had to modify it because the surgeon might have tried to add something to it at a different time. I hope this does mean you are approved for surgery.... Jennifer

[Tina254 0]

**Update and Questions**

I called Triwest and they told me that my first doctor appt for my consultation is approved and the reason they had “Modifications” on there is because I didn't chose my doctor yet. I did choose my doctor and made my appt, yay! Has anyone been denied the surgery after the first (approved) consultation with the surgeon?

I forgot to ask the lady I talked to on the phone from Triwest. Can I print out the approved status I got online and bring that to the doctor or do I have to wait for the letter in the mail?

Another thing I saw on my online status that I don't quite understand and I forgot to ask is about the other thing on there. There are two things with "approved with modifications"...

~"office consultation: Approved w/Modifications " &

~"office/outpatient visit, new: Approved w/Modifications"

So I know I'm approved for the consultation but what is "office/outpatient visit, new"?, it says I'm approved for it but I don't know what that’s for...I'm thinking it’s the next appt after the consultation but I don't know, just asking to see if anyone has had this on their status online or approval letters and if they might know the answer. It’s a holiday weekend because of the 4th so I won’t be able to call until Monday so that’s why I’m asking you guys

Thanks for all the answers on my questions really appreciate it!!!

Edited July 3, 2009 by chrystinaw