Need Advice-Tricare Prime Denial
I need some advice. My surgeons office made it seem like it would be a piece of cake for me to get an approval from Tricare since I am 100lbs overweight and have sleep apnea. However, once they submitted my application I was denied. What is the best way to go about appealing this decision, and can anyone give me a good appeal letter template for writing an appeal letter. Thanks.
Wow I am surprised Tricare denied it. Their requirements are BMI 38 and above, 100 pounds, co morbities and have to have proof of failed diet plans.
I would talk to your PCP and put some weight on, I hate to say that but I did it. See if your PCP can make it sound more dire than what they previously wrote. Good Luck, let me know how it goes for you.
I would talk to your PCP and put some weight on, I hate to say that but I did it. See if your PCP can make it sound more dire than what they previously wrote. Good Luck, let me know how it goes for you.
HW-220 SW 205 4'11"
I would want to know exactly why you were denied before writing the appeal since you will want to address those issues.
66 yrs young, 4'11" hw 220, goal 120 met at 12 months, cw 129 learning Maintainance
Between 35-40 BMI? join us on the Lightweight board. the Lightweight Board
Here is the Tricare Criteria....find out specifically why you were denied and the Interqual issues.
The following conditions must be met:
- The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints; or
- The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions; and
- InterQual® criteria is used during the authorization process to determine if the requested surgery is appropriate and medically necessary. (InterQual® is a widely used product of McKesson Corporation that provides evidence-based clinical decision support for health plans, hospitals, government payors, and various other organizations.)
Gosh I don't know, I was only 80lbs overweight, but I had high bp, diabetes, high cholesterol, sleep apnea, hip and knee pain. I didn't have to do any diet prior. Oh yeah did your PCM put in the referral to the WLSurgeon? The first referral has to come from your PCM to the surgeon. What region are you in, I have heard different regions approve differently.
I will live each day in the mindful present
HW 208/SW 197/CW 115/1st GW 130/2nd GW 120/3rd goal 115/New GW ??/HT 5'2" NO MORE WEIGHT GOALS
Thank you to everyone that told me to appeal and gave me words of encouragment. I finally finished my appeal and submitted it last week. Tricare overturned the original denial and I am scheduled to have my surgery performed on Dec 15....perfect Christmas gift and way to start the New Year off right. Thanks again!
Excellent and congratulations!
--gina
--gina
5'1" -- HW 195/SW 187/GW 115 July 08/CW 121 Dec 2012
******GOAL*******
Starting BMI between 35 and 40ish?
Join us on the Lightweights Board!
DS on Aug 9, 2007 with Dr. Hazem Elariny
Most Active
Recent Topics
