Advice on filing appeal with Tricare Prime

[dl2418 0]

So about a week ago I got the call saying Tricare wanted more info. Well I couldn't get into my PCM until Wed. I got a letter from Tricare today saying that my banding was not approved. (by the way there's still nothing on the triwest site, I've been looking since it was submitted).

So, can anyone give me advice on how to appeal? They wanted a letter from my PCM stating that the joint pain from arthritis was interfering with ADL's or X-rays showing arthritis. However my PCM didn't want to do the X-rays because even with arthritis the X ray may not show abnormal and he agreed to write the letter. Should I get records from my dermatologist who prescribed me Enbrel for my psoriasis (which can cause arthritis) as well as the letter from my PCM?

Any advice on how to go about this and get it approved would be greatly appreciated. Has anyone had it denied still after appeal?

[lanna 0]

I also have tricare prime and had heard the approval rate was good. Now I'm a little worried. I have my surgeon consult on March 2nd. Did they say if you had enough medical issues that were addressed to your weight? They say that is a big factor. Well, I wish you the best and I will be so relieved after I find out if I get approved or not.

[chicamam1 1]

First you will want to find out how the appeal process for your ins works. most of the time its submitted in writing. What you want to do is a get a list of information you need to submit that caused the denial in the first place. Then you want to work with your doctor to submit very specific documentation chart notes etc. This will have them review the denial and then the documentation showing that it should of been approved. Address every issue leave nothing out. If one thing is missed it can lead to another denial. Be sure to find out what the turn around time is for the appeal. This is what you can do. I wish you the best of luck.