Denied by Tricare Prime

i was denied by Tricare because I didnt have any of the majors IE: high Blood Pressure, diabetes, narcolepsy, hypertension, or severe breathing problems. After being denied my PCP was really mad and sent me for a sleep study for sleep apnea. We are all hoping it will be approved. Has anyone ever had this happen? Did you get approved because of sleep apnea? Just trying to figure what my chances of approval are.

I just recently got denied becasue I didnt have any problems, but was approved because I was 200% of my ideal weight when I appealed. Are you close to the 200% mark? If not, what kind of problems do you have?

I am not close to 200%. Im 100lbs over my ideal body weight, I have severe sleep apnea. Need a CPAP machine. I have a lot of small problems like bladder problems, irritable bowel syndrome, Severe back pain everyday, moderate knee pain on occasion (when climbing stairs, walking or running), heavy and very painful menstrus, lack of energy, I think I have GERD. I know I have severe heartburn alot. Depression and super low self esteem. Im tired all the time which is probably from the sleep apnea. But tricare doesnt seem to care anymore about the small stuff. They recently have been denying people left and right. I did my sleep study and we are appealing so maybe they will approve me. My PCP says he will give me my referral over and over if needed. And he says "if theres a will, theres a way and Ill find a way to get you approved" He said we will just keep digging until Tricare approves me. He was really mad I got denied because he doesnt want to see me have surgery on my back as he thinks surgery will make my back feel worse. So at least I have him, Liv Lite, and the surgeon, Dr Narscisso on my side. They are all wonderful and are fighting my battle for me for the most part. They point me in the right direction and I do what they say. Hopefully I will get approved after I appeal. Im keeping my fingers crossed.

That's so strange that Tricare would deny you when you seem like a good canidate. I was approved before I had my Psych Eval done, before I had my sleep apnea testing done, before I had anything really, and they approved it in about 2 or so hours. Your Heavy and Painful Menses could also be because of PCOS... have you had that checked into? That would also help to get approved. Good luck to you, i hope you get approved. Krissy

That is really odd that they denied you! You do seem perfect for it. I was so upset when I got denied, but then my boss told me that a lot of insurance companies eny things like that to see if they can "turn you away" from it and save them money, and she said that once you appeal you have a better chance. I don't know...it made me feel better though. Just make sure that you submit all the documentation for the appeal. I also included a letter that I wrote with mine, explaining why the surgery wa necessary for me and that I knew the lifelong changes I would have to make. I also quoted them from the handbook and went on to explain that I did meet their criteria. And I had my doctor include a letter stating why this was medically necessary. Keep your chin up. Persistence pays off!!!! I'm living proof of that.

Well, Im glad you have so much support! The doctors i have seen for the most part could care less. I was denied because i need a co-morbidity too. I was re-evaluaded just 2 days ago and everything is going to be re-sent to tricare. I have hypertension, and that wasn't reported before, and i also have PCOS and back and knee problems so hopefully it will be enough to get me approved this time. One the doctors at an MTF told me that tircare has changed some policies since so many soldiers are comeing home with serious injuries. They are makeing it harder to get some things done. For example plastics are supposed to be covered but now alot of people are being denied and if they are approved they have a large co-pay. I honestly don't know how much of that is true because i haven't seen any policy changes on the tricare website so it doesn't really make sense to me that they would make changes and not inform people you know? Well, good luck getting approved. Let us know how things are going for you

They are going by BMI now, according to my dr's insurrance gal. Your BMI has to be over 40 or 35 if you have serious comorbidities. They were requireing that you had to be 100 lbs over your ideal weight. I'm not sure if that still applies. Good luck with your fight. Diana