Tricare Denial..REVERSED!!

[KarinaM 0]

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!!!

Sory for taking sooo long. So far I feel great I was at the hospital for 2 days (left on Wed) but I feel "head hunger" sometimes. I do not feel sick or nausea at all. Since I got the Gastric Bypass I'm still on stage 2 diet and sick of it. Missed you all. It took 21 bus days for Triwest to show on the website it was approved by TMA. I was going CRAZY with their delay and they kept telling me at Tricare I was not approved untill the very LAST day. TRIWEST SUCKS.

Thank you guys so much for all the support.

[KarinaM 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!!!!

It took 21 BUSINESS days to Triwest show the approval by TMA. It took a lot of horible time on the phone with Triwest and they kept telling it was under appeal and they could not do anything. Don't worry it will show on the very last day.

[jillcvt 0]

Hello, i know you wrote this post a while ago. but i also have tricare ins. do you mind sharing if you had any "comorbidities" ie diabeties, hypothyroidism, joint pain. anything like that or just heavy with a high BMI? i know its sharing a lot to someone you don't know but it would sure help with my insurance struggle.

thank you

jill

[munger 0]

Hi, I have high blood pressure - it was not being treated so they said I could not count it - I went straight to the clinic and go put on meds! I also have High cholesteral - same thing - back to the clinic! I was borderline on my weight 0ne day I was underweight the next I was 101 pounds over weight. So I went to the doctors office and had them weight me and take my average weight - I did that for a week. I had to have them measure my bones to make sure I was a medium frame - or I would not have qualified! I have lower back problems - but I am not sure if that had anything to do with their dession. I know if I were you I would document everything!! I would write a letter and tell how the extra weight affects you life and your family.Tricare does not go by BMI it simply does the weight charts. I would double check everthing - then I would fax it and as soon as I could I would call an make sure that they know you know that you qualify - be the squeaky wheel!! Good luck.

[munger 0]

Hi, I got a letter from the TMA - colorado - I am triwest. So I am approved - do I also have to wait to have a new letter on the web site saying that I am approved? I booked the surgery!! My dr. said I am approved and I am scheduled for March 16th. That is more than 21 days. So I should be good right?

[JamieNP 20]

You should be good to go Munger.

As far as comorbidities, I had high blood pressure and sleep apnea. I am still on my blood pressure meds, but I am off of my CPAP.

I am now am 3 months post op and wearing size 8 jeans comfortably. I still would like to lose another 20-30 lbs. I will just play it by ear. My last fill was about a week ago and I have good restriction. I have to remember to EAT SLOWLY!! I have also notice a lot of Hair loss. Thank goodness I have a head full of thick hair. Some may be from anesthesia and the rest from Protein, although I am trying my best to consume 70 grams a day.

[afmomofthree 6]

Hi there. I'm new here. I started my journey on 11/21/08. I had lab work, ekg and chest xray 11/22/08. I had my fitness eval 12/10/08 and psych consult 1/8/09. All submitted paperwork to Tricare South on 1/23/09. Just got the call from the surgeon's office today that I was DENIED by Tricare. She mentioned an appeal. I don't have comborbids but I am 5'3", BMI 42. I do have chronic back pain and exercising is absolute agony. Any advice or ideas. Do I need to write a letter along with my appeal? More documentation? Any help would be appreciated. Thanks!

[JamieNP 20]

Hi there. I'm new here. I started my journey on 11/21/08. I had lab work, ekg and chest xray 11/22/08. I had my fitness eval 12/10/08 and psych consult 1/8/09. All submitted paperwork to Tricare South on 1/23/09. Just got the call from the surgeon's office today that I was DENIED by Tricare. She mentioned an appeal. I don't have comborbids but I am 5'3", BMI 42. I do have chronic back pain and exercising is absolute agony. Any advice or ideas. Do I need to write a letter along with my appeal? More documentation? Any help would be appreciated. Thanks!

They are very specific on their guidelines. They DO NOT go by BMI, like most if not all other insurance companies. They go by the metlife height/weight chart (you can type that in your browser and look it up). If you have no documented comorbidities, then you need to be 200% over your ideal weight according to that chart. If you have not had a sleep study, see if your PCM can get you one. Most over weight people have some degree of sleep apnea (if you snore chances are good you have it). Document everything. Get as many docs as you can to right a letter of recommendation for you. Make sure your surgeon sent everything need in. Find out why exactly you got denied.

[afmomofthree 6]

Thanks for the post JWRN! I checked out the metlife chart...too bad they don't go by BMI because mine is 41.1. I have high blood pressure but my PCM didn't want to address it since I was going for the band. I could have screamed. I told her it would be helpful but no go. Maybe now I can go back and get her to do it and have it documented. I will see about getting a sleep study from her. She's a military doc and it's like pulling teeth to get things done. Anyway, I don't mean to rant but my surgery was scheduled for 2/20 and now I'm having to go through this. :cursing: Thanks for your help!

[sapphire12305 9]

hello, I have tricare also, I hope they dont deny me.. I'm 5' 7 and 246.

[azairforcewife 1]

munger, CONGRATS on your approval!!!!!!!!Remember i went through the same thing with the tma paperwork. for some reason tricare is not getting it for weeks finally i Told them im faxing it to you weather you want it or not and the next day 4 different people called. i do have a phone number for clinicals if you want they were the ones to get it staighened out.but if you have the paperwork your fine. my surgery is next friday the 13th and im getting so nervous!!!

[Jade810 0]

Congrats! I hope I don't have trouble with Tricare but knowing how they work I expect some.

[afmomofthree 6]

Hi all! Well, I talked with a friend of mine that is an RN in the or where my surgeon works and happens to know him pretty well. She wants to talk with him about me and see if there's anything he can do to help with my appeal since his coordinator basically told me I'm on my own. I haven't gotten my denial letter in the mail so I can start on my appeal. In the meantime, I am going to make an appt with my PCP and have her put me on those BP meds and make sure it's documented so I have an official comorbid on file. I'm not giving up until I have exhausted all avenues!!!

[munger 0]

Hi all! Well, I talked with a friend of mine that is an RN in the or where my surgeon works and happens to know him pretty well. She wants to talk with him about me and see if there's anything he can do to help with my appeal since his coordinator basically told me I'm on my own. I haven't gotten my denial letter in the mail so I can start on my appeal. In the meantime, I am going to make an appt with my PCP and have her put me on those BP meds and make sure it's documented so I have an official comorbid on file. I'm not giving up until I have exhausted all avenues!!!

I believe you are on your own - I was. I submitted an appeal twice - I wasn't really sure what Iwas doing - tricare nor the dr helped. I believe that you must:

Document your weight - your weight must be 100 pounds over the MetLife table - look it up and make sure send them a copy so they know you know you are 100 pounds over the weight limit.

Document your height - agian it must match up with the MetLife table. I had know idea that it was as simple as having your dr say you were a small, medium or large frame. But it has to be in there stated by a dr.

Document any co-morbs: I had high blood pressure and high chyolesteral - but I was not taking meds. I went to the clinic every day for a week and had my blood pressure and weight monitor and documented - they fluctuate so much and I wanted them to know I knew that! Then my dr wrot the average for the week - which was of course high!

Document your meds - My paperwork stated that one reason I was denied was that I was not "actively" being treated for my co-morbs. So I made sure that my perscriptions were up to date.

I quess that is all you can do. I wrote a letter stating how my life was being impacted by my excess weight - and how my family life was also affected. I am not sure that workedd - but I was approved after I did all this. Of course they took the total amount of time, I wrote my congressman (really a woman) and my senator - who just happens to be on the Tricare panel! So to make a long story short after 6 months and two appeals - I got approved!

I wish you luck - I think we all need a little.

[KarinaM 0]

Hi, I got a letter from the TMA - colorado - I am triwest. So I am approved - do I also have to wait to have a new letter on the web site saying that I am approved? I booked the surgery!! My dr. said I am approved and I am scheduled for March 16th. That is more than 21 days. So I should be good right?

The same happened to me and I was goin crazy because I had the letter from TMA saying I was approved, the lady at TMA told me to be patient and wait for 21 days so Triwest would give me my authorization so I got my surgery schedulle. Until one week before surgery would not show at Triwest and they would tell me I was not approved but the vary last day for the 21 bus days they had it got it posted online. YOU ARE FINE!!!!:biggrin: