Very Frustrated!

Butterfli2005
on 5/8/15 7:50 pm

In the beginning of April I saw Dr. Shoen for a revision. It was denied by Tricare. I went and had a consult with Dr. Chae and he totally agreed a revision was well worth in. Tricare (now managed by United Health Care) will NOT do a DS but will normally approve a RNY to an ERNY. Dr. Chae can and does that and has had great success with it. He has done over a thousand of them. So his insurance filed a request for approval. Which has been denied AGAIN. He is doing a Peer to Peer conference next Thursday with Tricare but there isn't a whole lot of hope. 
I want to give Dr. Chae as much ammo for this Peer to Peer conference. Here is the really frustrating and near impossible issue to combat:

In the denial for my original request with Dr. Shoen was it was a- not medically necessary and b- there was a one per lifetime limit on WLS

 


With Dr. Chae's request it was denied for one of three reasons depending on who at Tricare is giving the reason -


Reason one- Not medically necessary. Well I have well a huge increase in Migraine headaches which have gotten really really bad. This is documented and my next step is an implant in my head to help ease them. They have gotten so bad I cannot work, as they hit me at least once or twice a week (and that is with getting Botox injections for them every 3 months) I also have already had one knee that has had to be replaced and now the other one is going out. I have gained 102 lbs since my goal weight. I was meeting with a dietitian every two weeks and actually see a food psychologist every three weeks to help me.
There is a ton of medical research done that links directly migraines to weight / obesity
2) When I got the letter it stated the above. Dr. Chae had not received their letter so yesterday the insurance coordinator called them and they said it was denied because TriCare did not pay for the first surgery so technical failure or complications were not allowed. Tricare did pay, but it was out of network
3) When I called today it was that Tricare DID pay and there was a one surgery per lifetime. And also the medically not necessary.

So I just don't know what to do. The lady I spoke with at Tricare said today that if the peer to peer conference ended in a disapproval that was it.. no more chances. So subsequently I have to hire a lawyer to sue the damn pants off United Health care.. 
Have any of you had experience with them? They  just took over a year ago Tricare management and it is nearly impossible to work with them. I am so frustrated mad no make that furious and very much feeling like I have no where to turn. I cannot do the headaches much longer.. and honestly it is not so much about how I look (though that is there too..I have gone from a 6 to a 20 again) but what the weight is doing to me. And believe me I have tried and tried to lose the weight. No one in their sane mind, with the migraines I have, knowing that they are related to weight would not try their very best to lose it so they stopped!

 

Kathy S.
on 5/9/15 10:16 am - InTheBurbs, XX
RNY on 08/29/04 with

Head over to the Duodenal Switch Forum (DS) and perhaps some of the DS'ers will have some suggestions

HW:330 - GW:150 - MW:118-125

RW:190 - CW:130

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