Denied

Hello to everyone out there I am new to the site and I just wanted to intorduce myself a bit. I have been researching this surgery for 3 years. over the last five years I have been gaining weight. fluxing with diets and weight loss aids.I am to the point of no more yo yoing for me. I have recently been diagnosed with type 2 diabetes, mild sleep apnea and I have asthma, elevated blood pressure and cholestorol(up and down) my current weight is 237 I have tremendous lower back and joint pain. months of testing and doctor appointments I finally got a referral to see a bariatric surgeon.I even checked with my tricare provider to see if they coverd the service before hand.THe answer was yes. much to my surprise I recieved a letter of denial stating that I don't have any co-morbidities and I am not on any medication. I am currently being treated for diabetes and asthma and I was givin motrin for pain.does that count for anything. Am I missing something here or is it a over sight on their behalf I was told I have the right to an appeal but I am not sure what they want from me. if anyone out there has Tricare prime/Healthnet and has any suggestions on how to go about my appeal process please email me. or suggestions on how to get approved.

SA, While it does appear that you do have at least one co-morbidity, the diabetes, and possibly others, you did not indicate what your BMI (body mass index) is. Most health insurance plans that do cover the bariatric surgery follow the suggested NIH "guidelines" (I put that in quotes, as they're not formal guidelines, but factors outlined in a "Consensus Statement"): the surgery will be found to be medically necessary if the patient's BMI is 40 or higher; or between 35 and 39 w/at least one or more comorbidities. You indicated that you currently weigh 237; what is your height? There are a number of sites online where you can put in your height and weight, and the BMI will be calculated for you.

Hi Leesa my weight then was 237 and my BMI was 38 and my height is 5'6 today I went to the doctor for my back pain and I weighed in at 244 and that made my BMI at 39. my insurance is tricare prime and want me to be 100lbs over my ideal body weight and a co morbiditie apparently they use a weight table called the metropolitian height and weight table. every table that I have used put my bmi where I need to be to qualify. tricare prime is giving me a hard time. every other site that I have been to does not used this chart. not even the bariatric surgeon I went to. I don't know what else to do. I am currently starting an appeal.

I have not heard of any insurance companies using the Metropolitan Life Insurance Company height/weight charts for purposes of qualifying patients for weight loss surgery. Those charts usually separate people by those who are small, medium and large frame in stature. I'm also 5'6", but started at a much higher weight. (My insurance wouldn't cover the surgery, but simply because it was excluded.) I have heard that Tricare can be finicky and inconsistent to deal with. Get as much documentation from your doctors as possible for the appeal process, especially with regard to the diabetes and blood pressure issues, as those are classic co-morbidities. Good luck!

And also the sleep apnea should qualify you, right? From browsing through people's profiles on here, I noticed that many people were denied the first time -- almost as a formality -- and later approved. So keep trying.

The comment by SA about sleep apnea was that it was "mild" -- so I don't know that it, alone, would qualify as a co-morbidity. (I know I was diagnosed with severe obstructive sleep apnea.) Depending on the insurance plan, many people are approved on the first go-around. Tricare is a military-based plan, but administered by a private company. As something that comes from the Federal contract level, I don't believe it is subject to Maryland statutory jurisdiction.

Honestly SA, I think you need to get a second opinion with another bariatric surgeon. I went through something similar with Magnuson, he's an excellent surgeon but the practice there is just too busy in my opinion. My current surgeon would not even submit for approval until they had all the neccessary paperwork in place according to what my insurance required. It took a little longer, but they did that for me. An entire team was working on my case and eventually I was approved, on the first try. Part of that was the insurance I have and part was due to the team working with me to get the approval and the program that I chose. I saw Magnuson for an initial consult (20 minutes) 1 year ago and they said I was all set, ready to submit, all I needed to do was get the psych eval. I tried to reach them with a question and it took 2 months for them to get back to me. By then, I sought the second opinion and things were drastically different. My initial consilt with the current surgeon was over 3 hours. I was treated like a real patient from day one. The team at my current surgeon's office researched what my insurance required, told me what I needed to do and got the approval. Everything you described are qualifying comorbidities, even the mild sleep apnea. Mine was mild too. Sounds like the surgeon didn't submit proof that the comorbidities exist. Did they mail you a copy of their submission? See if your PCP will prescribe a mild medication for the elevated BP, fill it and if it works, great, if not, at least you have it on file that you were taking a BP medication. How about back or leg pain? If you have it, even mildly, see an orthopedic doctor and be sure to tell him that you think your pain is stemming from the obesity and that you'd probably feel a little better if you could get some of the weight off. You might get a rx for pain or inflamation, which would also qualify as another rx. Meanwhile schedule appt's with your PCP, see if he/she will do a 6 month physician supervised weight loss program. You're insurance may require it and even if not, it looks good when you submit for approval. Good luck, don't give up and get lots of information from local resources. Including your insurance company. I called mine ahead of time and they emailed me a list of requirements for approval.