Tricare Denial..REVERSED!!

[Maggies 0]

azairforcewife, Congratulations on your approval. It took an appeal for me to be approved also. I am happy with the way I am losing. It is slow, but going down.

Munger, Keep trying and you will be approved. It is hard to believe they are taking so long. My surgeon actually talked to Tricare and submitted the appeal with the sleep study included, which wasn't in there the first time. Has your surgeon talked to Tricare??? Good luck and keep trying.

Maggie

[KarinaM 0]

I'm so excited after 6 months of fighting with tricare , I finally won !!!2 appeals and a formal appeal to tma. It really pays to fight for what you want . surgery in Febuary!!!

I'm so happy for you. We are in the same boat. I was denied and they took 54 days on my appeal. I gained more weight to qualify on the 200% and sent a secont appeal and this tima it was to TRICARE, not TriWest and it was appoved in 17 days. I'm still waiting on TriWest to release my authorization since they have 21 days to give it to me by the time they receive the decision from Tricare. My preop is next week and surgery on Jan 6th. Can't wait.It was VERY hard to fight Tricare but I WON.

[azairforcewife 1]

ok munger so this is how it happened! I am 5'4 and 236 with blood suger problems and they came back with a denial for not having problems long enough. So the second time i had my psm look at the met life charts and messure my arm for frame size so i could also quilify under the 200% and sent that in and was denied again so i then sent it to the formal review board (tma) secratery of defense where they have 60 days to review!! I have to say i was ready to quit and thats what they want but my wonderful husband said "no we are going to fight this they want you to give up."Send them everything the met life charts hilighted frame size,all your med records and a personal letter on how it affects your life from day to day ,self esteem and how lapband will help with blood pressure etc.. Make it personal !!!!i think i sent them 53 pgs of info.make copies of there polices .Dr.monash will do a peer to peer rewiew leave a message for him personally .Hes ofice staff is a little flakey!! If you have any qwestions just ask. O' and the last weigh in for the 200% i was 255 wearing everything i could think of quarters etc...

[munger 0]

Well I think I did all that - my husband is supportive - but he is about tired of my ups and downs evertime I get denied or delayed. I did send in everthing aging - new weight, blood pressure ... and yes a personal letter. I just feel like this is a merry-go-round and there is no end. I was hoping to have the surgery before school started - it seemed to be so very simple- black and white. I read the regs and knew I quailfied! But it seemed that one thing was left out, then another not documented long enough.... I really "hate" the lady at Tricare and she is not the one that makes the dessions! I called her again today - because she said a couple of weeks and I should know something. Today she said "you misunderstood me" now it seems that they have until Jan. 27th - so I figure - 2-3 days to get it off her desk, 2-3 to float around the office, 3-5 days to get down here by mail and I will know something around the end of Feburary!! She got a little peeved when I put it that way - but hey I have been waiting for 6 month!

Again - everytime I read that someone won a deniel I am happy - it gives me hope. I am truly happy for you. I hope someday soon I will also be able to say that I won my appeal.

[KarinaM 0]

ok munger so this is how it happened! I am 5'4 and 236 with blood suger problems and they came back with a denial for not having problems long enough. So the second time i had my psm look at the met life charts and messure my arm for frame size so i could also quilify under the 200% and sent that in and was denied again so i then sent it to the formal review board (tma) secratery of defense where they have 60 days to review!! I have to say i was ready to quit and thats what they want but my wonderful husband said "no we are going to fight this they want you to give up."Send them everything the met life charts hilighted frame size,all your med records and a personal letter on how it affects your life from day to day ,self esteem and how lapband will help with blood pressure etc.. Make it personal !!!!i think i sent them 53 pgs of info.make copies of there polices .Dr.monash will do a peer to peer rewiew leave a message for him personally .Hes ofice staff is a little flakey!! If you have any qwestions just ask. O' and the last weigh in for the 200% i was 255 wearing everything i could think of quarters etc...

I also got approved by TMA the Secretary of Defence contractor. They were very nice and I will tell you I got the surgeon to say I was small frame so I was approved under the 200% (by the way I had to "add" some 20lbs weight on me if you understand). It worked and I thing we have to do what we can to get approved since they do not understand this is no "cosmetic" liek they think it is. Good luck munger.

[munger 0]

I also got approved by TMA the Secretary of Defence contractor. They were very nice and I will tell you I got the surgeon to say I was small frame so I was approved under the 200% (by the way I had to "add" some 20lbs weight on me if you understand). It worked and I thing we have to do what we can to get approved since they do not understand this is no "cosmetic" liek they think it is. Good luck munger.

I am not sure what else I can do. Again I have resubmitted everything. The lady I am talking to is Bridge Ewings - and she changes her "statement" everytime I call her. One day she says they will give me an answer on this day - the next time it's 4 weeks later and she said it will be a different day. I have followed the regulation via tricare rules and I qualify - they just simply refuse to make a desission! I shoudl know something by the 27th of this month - but they way things are going - what I will find out is they need 2 more weeks to make a desision or I have to send them more info. I start another diet tomorrow - I am almost sure it wont work - I have to do something though. I wish it was the high protien diet that would get me ready for surgery.

[JamieNP 20]

Karina, are you getting excited about your surgery? It is coming up fast! I am down to size 10's and can squeeze into 8s..doing 90 min of cardio 4 times a week and lifting weights. My weight loss has slowed down, but I think it is due to muscle gain. Can't wait for you to have your surgery..it has been a long hard road. I will be there in spirit!!!

[azairforcewife 1]

munger,

Is your paperwork at tma and are you at dm because there is a lady on base that can talk to tmaand see the statis of your appeal she works for the people but for tricare? Don't give up ,i was the same way !

[munger 0]

munger,

Is your paperwork at tma and are you at dm because there is a lady on base that can talk to tmaand see the statis of your appeal she works for the people but for tricare? Don't give up ,i was the same way !

My paperwork is in denver! I submitted in again in December. I am down at Ft. Huachuca and the people here at the tricare office can't/won't help anyone! I talked to them several times trying to get this to be written up well so it would pass - and they would not even call and find out what mad it a "factual" deniel! I only have a few more days to wait on the appeal - I am hoping to know something by the 27th (Like they have met a deadline yet). But yes, all the damage is done - I am just waiting.

[azairforcewife 1]

munger,

I'll be crossing my fingers for you! tricare is still giving me problems even after being approved !!!!! they are saying they still don't have records from TMA saying i was approved and they won't take my faxed copies from the 5th of jan , I'm so sick of having to call everyday and nobody knows anything!!!!

[munger 0]

munger,

I'll be crossing my fingers for you! tricare is still giving me problems even after being approved !!!!! they are saying they still don't have records from TMA saying i was approved and they won't take my faxed copies from the 5th of jan , I'm so sick of having to call everyday and nobody knows anything!!!!

They should have faxed you dr. too! and he can go up on line and get it!! I feel for you - if it is not one thing it is another. I want to know if I get approved - how long will I have to get the surgery? I teach and I did want to do this over a vacation - well summer came and went, fall break, thanksgiving, christmas. Gosh I've been at this a long time. How long did it take you?

Well - I just got a letter form Sen. Kyle. They seem to want to help. I wrote them a letter complaining about how long it is taking and how little they care about us. I have given them permission to look at my medical records and see if they can help. I made sure I let them know that this has taken over 100 days - I even sent them in the Tricare regulation and met life weight table. I hope this does some good.

Good luck on your surgery data!

[azairforcewife 1]

munger,

I started all this in june so its been well over six months and the dr said surgery dates were either the 13th or 20th of feb it seems so far away!!!Has it been sixty days since you submitted everything to tma because thats their time frame. I'm so sick of weighing 236 i just want to be in wonderland already!!!!!!

[munger 0]

munger,

I started all this in june so its been well over six months and the dr said surgery dates were either the 13th or 20th of feb it seems so far away!!!Has it been sixty days since you submitted everything to tma because thats their time frame. I'm so sick of weighing 236 i just want to be in wonderland already!!!!!!

OMG I turned my stuff in to them in OCTOBER!!! They were suppose to have me an answer Dec. 13th - but that did not happen. They asked for more stuff - or shouldI say the same old stuff on the 12th of Dec. and the whole *&*^& started over!!! I am also tired of being 236! I do not want to diet (like that would work anyway) until I get an answer - just incase they want me to weight in again!! The bad part is I guess I am just getting really tired of all this. I think that the lap band would be so great. I have read everything I can and it just seems perfect for me. But at the same time I feel like I should be doing more for me right now My husband goes TDY to DC at the end of the month - that is when I should know something. I would love to tell him that I am approved when he gets back. I guess we both need alittle luch right now.

Hope wyour wait is over soon!

[azairforcewife 1]

I was the same way not wanting to diet just in case they wanted me to weigh in again!!! What are they saying is relaying all this u are the same height and weight !!!!! omg i hate tricare!!!! now i fell i need to eat crap before my surgeery What am i thinking!!! ginnie

[munger 0]

I am not sure. It is like they keep loosing all my stuff and I have to resubmitt it!! First my medical records only stated that I had high blood pressure - but I did not have my prescriptions listed. Then my did not specify that I was medium frame - eventhough with my weight - I qualified for large frame too! Now they are just relooking at everything - back in Dec. they had me resubmit EVERYTHING!!! I believe like they said at the Dr. office - they simply do not want use to have this done - so I am still not sure why they said we could!!!