Denied by tricare prime =(

[DeterminedWifey 0]

I was denied by Tricare Prime west region (triwest) for gastric bypass. I am OVER 100 lbs overweight and a bmi of 42 with NO comorbidities.

I plan on appealing but what can be my fighting arguement since i have no documented health problems, no diabetes no hbp etc.. ?

I do not want to give up, do i have to finally get to the point of becoming diabetic for them to approve me?

Iam disappointed, but if anyone can give me any pointers or tips about how to make my appeal It will GREATLY be appreciated.

Also, does triwest automatically go by the medium body frame on the metlife chart? Or can my surgeon simply state iam small framed, if so i meet the 200% over requirement...(small framed)

[Busybee424 0]

What was their denial reason? When I worked for an HMO the appeals department always looked for key points like Quality of Life/Living and emotional distress. Those were always key points that helped an appeal. Good luck.

[DeterminedWifey 0]

Thank you for a speedy response!

I just spoke to tricare and they said the reason for denial was because it was not medically necessary..

I plan on writing a letter and sending pictures from my childhood, any other ideas?

[HeatherO 7]

Perhaps your physician or surgeon can write a letter of medical necessity for you. You should definitely try to appeal if you can and provide whatever documentation that the insurance or your doctor's office suggests to strengthen your request.

[babyka16 0]

i know this is a few months too late but it could be because your under the age of 25! dont ask me its dumb i know....

[talkalot1981 5]

With Tricare you have to be at least 100 lbs over weight WITH com-morbities. If you have no co-morbities then you have to be 200% of a normal weight. Tricare cares nothing about BMI... I am sorry this has happened. Have you checked every type of co-morbities? I hope you have better luck

[erinshel 0]

i was approved with Tricare with NO co-morbidities. I had a BMI of 43 and was over 100lbs overweight. Appeal it.

[Tina254 0]

Does it matter if you are under 25? :thumbup: I'm 23 and I've read that if you are under 25 that you can be denied but then again I read a lot of people younger then me getting approved so I don't know what to believe...Does any one know?

[babyka16 0]

yeah same here! i think that it has to do with some insurers. Ive read in a few places that you have to be at lest 25 years of age ( i guess that shows you have been overweight for at least 5 years of your adult life) who knows these days. i really think it all starts out with your PCM! i think the way they put in the fourm to tricare plays a big roll in everything. i would try to go back to your PCM and have them resend it!!!! then call tricare and ask what the deal is, if they dont know i would ask to talk to someone who does. ive called tricare about 5 times in the last 2 weeks and they seem to be very nice and understanding!? i hope that you get through. best of luck!

[babyka16 0]

Oh and see if you can do the LAPBAND and not the GB they might go for it then. allot of tricare people seem to get the lapband over the GB. but i really dont know for sure because im not geting the GB and really have never looked it up!

[DeterminedWifey 0]

Well it turns out the reason I was denied was because I had none of the co morbidities that are required for triwest to cover the surgery.. Simply put there are no gray areas in the approval process(ie; age requirement)- from what I was told.

On a more recent note, turns out I have hypertension and have been put on meds. So I decided to appeal and am now waiting to hear back from triwest.. If it takes the entire 90 days ill have a "yes" or "no" by october.

[SuzanneG 1]

Determined, good luck with your appeal. I too had to appeal. Sounds like you've already sent yours in, but if its not too late, I would suggest getting letters of support from your doctors.

I wrote 2 letters from me, one medical, one emotional and then went to each of my doctors (gyn, gastrointerologist, podiatrist, GP) and asked for letters of support and then submitted the entire thing as a package. It certainly got their attention, the ins rep called me directly to tell me they decided to approve me. I've shared my letters with dozens of folks on LBT and would be happy to do so again if you or anyone else would like to use them as a template.

Keep us posted and good luck!

[tkee99516 1]

I was initially denied by Tricare. The surgeon's office had told Tricare I was a medium frame. I went back to my other MD & had him (really me - he just signed it) write an appeal letter stating I was small framed (it was legit - had the nurse measure my elbow). Sent it in & Tricare took ALL 60 days & then came through & approved the Lap Band (set for 8-25-09). I suggest you measure your elbow - you never know....

Tammy

[DeterminedWifey 0]

Well i just checked my status on the triwest website and ive been approved!! I didnt want to post until i recieved the actual letter in the mail and it too says the initial denial has been overturned!! I'm so thankful it didnt take all 90 days, Thank you EVERYONE for your info and suggestions!!

[SuzanneG 1]

DW - Congratulations! I don't know why they make us jump through hoops like that, but very happy that it worked out for you!