Tricare Approval or Denial??

[JamieNP 20]

Hi, 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.

[cobrien78 0]

Thanks for posting this! My surgeon's office is going to submit the paperwork to tricare this Friday. I have a strong feeling I will get denied. Probably cause I am pessimistic, but I have co-morbidities that aren't being treated. The nurse at my surgeon's office said that could be a problem.

So I'm ready to appeal and get copies of my medical records and letters together to send to them. I'm over 100lbs overweight and have PCOS w/ insulin resistance that is being treated, hypertension which has been treated in the past but no other dr. has treated me for it cause they've all said "lose weight", I also have high cholesterol which has been treated in the past and once I ran out the other dr. I saw said "lose weight". So I'm hoping I will get approved but not TOO hopeful cause of what the nurse said. The only thing I have to do is see nutrionist and have psych eval. I also have an extreme family history of heart disease. Who knows I will post when I find out. Wish me luck!

[gina s. 0]

Cobrien78, I wouldn't worry about it.....what you've posted above is way more than I had. I was borderline on weight, and only had one co-morbidity. The co-morbity I had was diet controlled diabetes (I was never actually diagnosed as diabetic, but I did have a history of high blood sugar readings on record). I had no problems, and I don't think you will either but I'll wish you luck anyway.

[JamieNP 20]

Good luck Cobrien! Maybe we will find out the same time!! My doc is submitting mine sometime this week (as soon as the PSY report gets written up...and I am NOT crazy, by the way!!:cry_smile:).

[aculberg 0]

I just found out that I am approved, and I too, was quite worried about it b/c I was on the borderline of the 100lbs, but I did have hypertension, and some other co-morbids that Tricare doesnt recognize. Mine kept saying "pending approval" for over a week, so I called them and turns out they needed more info, that I then faxed to the surgeons office, which they submitted back to Tricare and viola, I'm approved! So, stay on top of your paperwork, and keep up with what the surgeon's office is doing and also Tricare, dont be afraid to call and see whats up!

[lisa"stime is n 0]

ok so i saw the doc last friday, went to the seminar and filled out the new pt registration tuesday night. I called my doctors office and asked if the referral had been requested and NOPE, it hasnt been done. so i drove over after work and gave then a request form to fax records to the center and let them know i needed a recomendation letter. her assistant gave me the deer in the headlight look. i think they will be the hardest part in all of this. it is so frustrating when you are soooooo excited to get your life back. keeping the faith, ya'll take care :w00t:

[cobrien78 0]

So last week I went in to get my cholesterol checked (again). Today, I get a call from a med tech that some dr. who wasn't even the one who ordered my test is referring me to the "cholesterol class" at the HAWC!? Seriously? AND I asked the tech what about meds, and he said all I can do is tell you to exercise! Wow! Gotta love military clinics!

SO anyway, I'm calling and making an appt. with my PCM (whom I haven't met and will probably be a total jerk) to get meds for cholesterol and my high blood pressure. I'm not looking forward to it because the past few dr.s I've seen NEVER want to prescribe me anything they tell me to diet and exercise. UGH! I'm at the point that I really hate dr.s!

I really want this surgery, I feel it's my last resort before I really start going downhill. I know I'll appeal the decision if I get denied but I feel like I don't know what I'll do if I get denied, I'll be so upset. I feel like the military doesn't want to help me.

[JamieNP 20]

Cobrien,

When you go to your PCM, hand him a list. Include the following:

1.Medications and allergies (if no allergies put "NKDA"

2.Medical history (include anything and everything, esp if it is related to weight)

3.Weight History. I went back to my teens, to now...like every 5-ten years.

4.Every single diet, exercise program, dvd, gym, weight loss program, weight loss medication (Rx and over the counter) that I have tried. Put in there that you lost weight on most, but ended up gaining back more.

5.Family Medical History...everything weight related...cardiac, diabetes, etc etc

6. Cut and paste Tricare's requirements for weight loss surgery. You can get it online from the hand book or find it on one of your threads.

7. Met life's height weight chart. Highlight your ht/wt

8. Figure your BMI

9. List all of the tests/steps you have taken to get this surgery...like the requiremets, ekg, sleep study, labs, psy eval, meetings, etc, etc

10. Just for good measure, you can add some research articles.

11. All of the doctors that you have seen over the past several years...esp if you have seen then for weight related issues. Put their phone numbers on there.

I handed this to a PCM that had never seen me before. He was so impressed that he wrote the referral with no questions asked. I told him I was a nurse and I had been researching this, and that I have had patients and coworkers that have had the lap band and GB.

Make sure that he orders the following things for you:

CBC, BMP, Thyroid tests, EKG, Lipid panel. I wouldn't hurt to get a sleep study if you are borderline. Go ahead and go to any and all meetings you can attend.

Good luck!!

[bama_belle 0]

I had to fight with United Health Care, because they wouldn't pay. (we have both insurances). I have Tricare Prime.

I went to my PCM, he wrote the referral and faxed it.

I had an appt. with Dr. Stahl within two weeks. That was April 7th.

I saw him, they submitted the paperwork that week.

Within two weeks I was approved. That was April 14th.

I had the surgery on May 29th.

[cobrien78 0]

Well, my appt. with my PCM is August 13. Should I take all that stuff when I just want to discuss my cholesterol and blood pressure? I already have the referral I just want some treatment for those conditions because it will be better that it's "documented" when they send in the paperwork to tricare. At least now, I know they have my medical records. I'm waiting for a call back for the cholesterol class.

I think I will cry if my PCM is a total jerk and won't listen and won't prescribe me anything. I am going to ask for a sleep study because I think I have at least a slight degree of sleep apnea. I'm so tired of dr.s NOT doing anything but telling me to lose weight to take care of my health problems. It's so frustrating!

[aculberg 0]

I totally agree with JWRN - be prepared, go armed, and DONT take NO for an answer. It helps if your PCM is a civilian, in my experience, military docs are just mean. Probably not all, but mine were. lol You just have to stick up for yourself and tell them this is what you want!

[cobrien78 0]

Oh I am of the mindset I'm NOT leaving without meds! HAHAHA! That is how I went in to get my referral. The dr. who gave me my referral was a total A$$hole and we had an argument but, I got my referral. I realize now I kind of did this backwards but at least I'm getting it done. Right now I have a tentative surgery date of Nov. 3 of course I have to get approved by Tricare and then if that happens it may be moved up. I'm ready for this surgery, it's what I want but more so what I NEED. Therefore, I'm not letting some a-hole military dr.s get in my way or anyone else for that matter.:biggrin2:

[Divamom 1]

I didn't have to do it but if you are borderline on your weight, think about ankle weights and just wear long pants or jeans to your weigh in. There are also weight belts or weights for pockets. I know it's kinda cheating but but if are only alittle under it's a way to buck the system esp. if you have co-morbidities.

Just a suggestion I have read about others doing this to beat the insurance's system of 100lbs over.

[aculberg 0]

Ummm, the only problem with that is...my surgeon did kinda a mini physical and actually checked my ankles (for edema) and my stomach (for scar tissue and adhesions), so I'm not saying *not* to do it, just beware! That would be totally bad if you got caught!!

[JamieNP 20]

Before I got to the exam room, the nurse asked me to take my shoes and socks off to step on the scales...I think it had a body fat measurement thing on it..