Tricare Approval or Denial??

[cobrien78 0]

No it's because I only have PCOS with insulin resistance and no other technical co-morbids. I have had them in the past but my current PCM and referral doc don't want to diagnose me even though I DO have hypertension and elevated cholesterol because they know it will help me get the surgery and they don't think I need it. So, I had the nurse send in the paperwork anyway. She said she didn't know if they would qualify me because of the lack of co-morbids. I'm only 20-30 lbs from being 200% over ideal body weight. Who knows, I'm preparing for a back-up plan cause I don't think I will get qualified because of the ASSHOLES here at Malmstrom AFB! Seriously, my PCM all but said I was lying! I'm going to patient advocacy Monday. Hopefully I'll hear something about my approval/denial on Monday. If I get approved I'm waiting till after I get the surgery and then I'm going to make an appt. just to rub it in the bitch's face!! (She's a fatty too) Just kidding I probably won't but it would be nice!

[SusieC 0]

It looks like you got your approval...Congrats!! I wish you luck!:thumbup:

[JamieNP 20]

If you all haven't heard already, I got denied. They said that I was 6.5 lbs under the required wt. When they read everything else to me, it said that I DID have the comorbidities, it was just that I did not meet the weight requirement, and then listed the requirement for me.

So, do I load myself down and put myself at risk for insurance fraud? Do I gain the weight, and put myself at risk for other things? Or do I just skip it and try another doc?

Looks like I will be gaining some weight!

[KarinaM 0]

I was denied today and I don't know he reason yet. I can't believe it.

[JamieNP 20]

Don't get discouraged Karina. We WILL appeal it and get approved!

[dianah_m 0]

i was also denied today to .. i missed the 100 lbs by 20

[KarinaM 0]

Don't get discouraged Karina. We WILL appeal it and get approved!

What it is getting me more mad is the fact I DON"T KNOW WHY I WAS DENIED. They told me I was denied by the Medical DIrector an dI need to wait for my letter on the mail (7 to 10 bus days).

I had a very bad day it was like the world had fallen on me. My husband was great and weants me to forget this hole thing and try to change my life habits and start exercise. I wish I could pay for the surgery....

Maggie good luck on your appt tomorrow. Let us know how it was.

[JamieNP 20]

Karina,

Have you talked to your surgeon's office? Tricare had faxed over a copy of the denial to them. They could probably tell you why. I would say it was the same reason I was, considering our stats were the same.

[KarinaM 0]

Got my letter from Tricare. Did not answer any of my questions. This is what it says:

Based on the review of the request for authorization, our physitian reviewers have denied the request. Tricare will not pay for these services because they are not covered according to the TRICARE Policy Manual. This is a factual determination based on the indication below.

Using the current Metropolitan Life Tables

1. <LI class=li_a>The patient is 100 pounds over the ideal weight for height and bone structure and has one of the following associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.
   
2. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
   

I really wonder if they considered me as a diabetic or not. I do now I am 228lb and 5'5 and medium frame so I guess I need at least 10Lb to 15Lb. I'm already looking for ankle weights and waist weights so I can weight in.

Any sugestions?????

[KarinaM 0]

I submited my appeal today. Pray for me people!!!!:thumbup:

[gimullins 0]

Does anyone have appeal letters I could have to go by to appeal my case to tricare? If s send them to me at gimullins2@yahoo.com ...Thanks

[SusieC 0]

Did tri Care cover all of the appointments such as the sleep study and the Phsy eval as well?

[Wheetsin 714]

i, I am posting this for those of you that have Tricare Insurance. Hopefully this will help ease the nerves of those who are waiting for approval.

I don't have Tricare, but I can speak for 3 who do. All have been approved and have had their surgeries. Two received approval in what I would consider immediate turnaround, while the third had a bit of a delay due to Tricare needing more information (some records were missing when the information was faxed in).

[gina s. 0]

Did tri Care cover all of the appointments such as the sleep study and the Phsy eval as well?

I only had the psych evaluation to do on my own, and Tricare paid for that. I didn't have to do a sleep study, and all of my pre-op testing was done by the hospital where I had my surgery (I went to a civilian hospital). All I had to pay was a $25 co-pay for the hospital stay. But it seems different for some people so I can only tell you what I paid, I'm not sure about everyone else.

[JamieNP 20]

Tricare prime north paid for my psy eval. She was in network. So far they have paid for everything, but the journey is not over with yet.