DENIED

I checked my status today and it says denied. I called to find out why i was denied and they couldnt really tell me ??? He told me to write a letter for reconsideration and fax it. I wanna show u guys what i wrote , I will send it tomorrow.I am really upset and hope my letter will do something.

Letter for Reconsideration Dear Tricare,             My name is Sarah Kennedy and this is a letter for reconsideration for Gastric Bypass surgery. I am also sending medical documentation from Bayne-Jones Hospital on Fort Polk that will help you in your decision. I have been diagnosed with PCOS (Polycystic ovary syndrome)about 4 years ago and I am taking 2000mg Metformin daily for it. Even with Metformin my symptoms from PCOS haven’t changed or got better. My husband and I have been trying to get pregnant about 3 years now but with my infertility, due to PCOS, it hasn’t happened yet. Even my Doctor told me that chances to get pregnant without a weight loss are minor. Another issue I have due to PCOS is major facial and body hair problems (Hirsutism). As a young woman in a superficial society, it is difficult to feel as attractive with these problems. I can’t go certain places or wear certain clothes because I feel embarrassed. PCOS also makes it harder to lose weight and keep it off because it slows down my metabolism. I have tried the last 8 years with many diets or groups such as weigh****chers to lose weight and keep it off; long term, none of them work for me. I recently just came off weigh****chers after 6 months and a weight loss of about 30 lbs. (October 2010 221.8 lbs., June 2011 185.4 lbs. and November 2011 208 lbs.). With my family history, my grandma died at the age of 70 from a heart attack and my grandpa died at the age of 50 from a stroke…I have been trying to stop smoking for many years, but every time I do, I gain more weight. Recently I have major skin problems such as boils and abscesses (which I have been told is a result of PCOS and weight gain). Two of them were so bad that they needed to be cut and packed for about 4 weeks but I have 9 to date since October 2011. It is proven that Gastric Bypass surgery helps to resolve 78% of PCOS issues. If I got the surgery my chances to get pregnant are higher plus the weight loss I will get through the surgery will also minimize my chances to get a heart attack or stroke. Through the new policy of Tricare I do qualify for the weight loss surgery because I did 6 months of weigh****chers, my current BMI is 36.7 and my comorbidity is PCOS and I am over 18 years old. I personally know other military spouses who got approved for Gastric Bypass surgery with a BMI under 40 and PCOS as their only comorbidity, and I have yet to be told why I was disapproved so please reconsider my case. Thank you!

Its a lil long sorry about that . Please let me know what u think about it or what u did if u got denied before.

Thank you so much

Sarah, rather than talk the getting pregnant or the excess body hair as a reason for having surgery, explain that those individuals with PCOS are a MUCH higher risk of diabetes, etc...here are some facts from a GOVERNMENT website that might help.

Also push to get tested for glucose levels (hbA1c), and sleep apnea. Bit diabetes and sleep apnea have a much higher approval rate for WLS.

http://www.womenshealth.gov/publications/our-publications/fa ct-sheet/polycystic-ovary-syndrome.cfm

the risks of complications (health problems) from PCOS, such as heart attack, stroke, and diabetes, increase as a woman gets older.

Women with PCOS have greater chances of developing several serious health conditions, including life-threatening diseases. Recent studies found that:

• More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance) before the age of 40.
• The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
• Women with PCOS are at greater risk of having high blood pressure.
• Women with PCOS have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol.
• Women with PCOS can develop sleep apnea. This is when breathing stops for short periods of time during sleep.

Other treatments. Some research has shown that bariatric (weight loss) surgery may be effective in resolving PCOS in morbidly obese women. Morbid obesity means having a BMI of more than 40, or a BMI of 35 to 40 with an obesity-related disease. The drug troglitazone (troh-GLIT-uh-zohn) was shown to help women with PCOS. But, it was taken off the market because it caused liver problems. Similar drugs without the same side effect are being tested in small trials.

Thank you so much for that information,. I will put that in there as well

What you really want to do is delete any reference to wanting to get pregnant or the excess hair issue altogether. Focus instead just on the really dangerous parts...

Not getting pregnant or having excess hair while being an issue can't be considered bad for your future health like the possibility of diabetes, stroke, sleep apnea, etc.

Try this one:
Dear Tricare, My name is Sarah Kennedy and this is a letter for reconsideration for Gastric Bypass surgery.

I am enclosing medical documentation from Bayne-Jones Hospital at Fort Polk. I was diagnosed with PCOS (Polycystic ovary syndrome) in 2008 and I am taking 2000mg Metformin (a diabetes medication) daily for it. Even with Metformin, I still have PCOS symptoms.

PCOS also makes it harder to lose weight and keep it off because it slows down metabolism. I have tried the last 8 years with many diets or groups such as weigh****chers to lose weight and keep it off; long term, none of them work for me. My family history includes heart attacks and strokes as cause of death.

Recently I have had major skin problems such as boils and abscesses (which I have been told is a result of PCOS and weight gain). I have 9 since October 2011.

It is proven that Gastric Bypass surgery helps to resolve 78% of PCOS issues. Women with PCOS have greater chances of developing several serious health conditions, including life-threatening diseases. Recent studies found that:

More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance) before the age of 40.
The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
Women with PCOS are at greater risk of having high blood pressure.
Women with PCOS have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol.
Women with PCOS can develop sleep apnea.

Through the new policy of Tricare I do qualify for the weight loss surgery having completed 6 months of weigh****chers, my current BMI is 36.7 and my comorbidity is PCOS. Also I am over 18 years old.

Please reconsider my case. Thank you!

Liz

wow Thank  you so much :) Thats is relly great  Thank you Thank you Thank you :)

I agree with Liz - stick to the medical facts and take out any mention of appearance, even the boils and abscesses.  I'd also take out the pregnant part, they may just see that as something else they'll have to pay for.  As far as the smoking, I thought it was a requirement that you didn't smoke for XX months before surgery?  Has your Dr said anything about that?  Smoking greatly increases the risk of ulcers after WLS.

Good luck and feel free to repost after you rewrite it - now I think about it, there's a forum for appeals, I think... you may want to see what you can find and ask there.  I'm sure others will have some input and advice too.

Thank you. Yes my doctor told me i need to stop smoking 2 weeks prior surgery. If i even get it ;(

Do take out that you smoke.  I was APPROVED for RNY via my insurance but it took MONTHS before my surgery was actually scheduled.  Since I had been approved in a previous calendar year (nov and my surgery was then scheduled the next March) I thought it best that I call my insurance company a week before surgery even though my surgeon's office said I was good to go.  When I called I found out that I had to get a statement from my physician that I had not smoked in the previous 6 months NOR had I used drugs.  I found this fascinating as I have NEVER smoked and this is clear in any H&P I have ever had.  I also had to send in proof of a thryroid lab (NOT requested previously) and thankfully I had just had my thryoid checked a few months before that as I was experiencing hair loss (most likely due to to scalp psoriasis but I was freaking out knowing I had upcoming WLS and could be facing MORE hair loss).  The moral to this long story is DO NOT MENTION anything about smoking!!!!! 

Good luck!!!!!

Jennifer

Thank you for ur tips :) I am so glad I have you guys here I really am :)

Would they not tell you why you were denied?  Can you request a denial letter stating why you were denied?  It would be hard to write a letter of reconsideration not knowing why you were denied.  It could be the smoking, it could be you need 2 co-morbidities instead of just PCOS. 

I would wonder if it might be because you are smoking.  Lots of doctors won't touch you if you are smoking.    I know you said your surgeon said you would have to stop 2 weeks prior to surgery, but I wonder if your approval is based on not smoking.

I would just want to make sure I covered all the reasons for the denial in my reconsideration letter so you don't have to do it again.

Good luck.  Hope they get you approved and on your way soon!!
Linda