Question:
Has anyone been approved with Tri-west but then denied?

I was approved by Tri-west for the surgery in December of last year. I was scheduled for surgery that same month but it had to be post-poned due to abnormal lab results. Now that the other medical issues have been resolved and I have been medically cleared for surgery (may 13,2005) Tri-west has denied me. Nothing has changed except that I gained 15 lbs. Can they do that? Now they say I have to submit an appeal which will take 6 to 8 weeks to get an answer. Would it be better to just have the doctor re-submit everything or just wait out the appeal process? Thanks, Kalena    — Kalena B. (posted on April 28, 2005)

April 28, 2005
sorry i don't have tri-west. do whatever you need to do to get approval. they approved you once and they should approve you again. don't give up. good luck and keep us in informed.
   — karrie777

April 28, 2005
In your denial papers what was the reason for the denial? Maybe there was something omitted. I would call them and find out why. A year ago my daughter was denied on the basis that Gastric Bypass via Laparoscopic was considered "unproven and experimental" Of course that is a bunch of hooey so she ended up having it done open. Starting in Feb. 2005 they started covering it again Laparoscopic or Open. Jen Layman
   — jenafwife

April 28, 2005
Just thought of something. Can your surgeon just extend the date from the old approval? I know my approval was good for 6 months. Its the dr's office that sets that date. I know I have had to call Tricare to extend referrals for Dr's office visits before and they did without any problems.
   — jenafwife

April 29, 2005
The only issue could be that your coverage changed January 1st of this year - before WLS was approved and now it's not. Even if they gave you a 6 month approval usually there is a statement in the letter about the coverage at the time of surgery will apply. Definitely call and find out why you were denied. I hope all works out well.
   — zoedogcbr