Question:
Tricare not approving when I meet their requirements

Has anyone else had issues with Tricare? What did you do to prove to them that you met their requirements? How long did it take to argue with them and get an approval. Ive got less than three months to get this done, due to the 6 month post op requirement, and I am scared.    — lizzieleprechaun (posted on January 12, 2007)

January 12, 2007
I am currently dealing with Tricare as well. I had an appointment with my PCM and she took down a very brief history of my problems and sent the information to headquarters for approval for my first initial visit with the surgeon. I have not heard any word yet on the approval and am nervous as heck. We have recently moved to Germany and I had to start the process all over here. I was actually approved for an appointment with a surgeon while I was back in the states, but I only had one month left there so they told me not to even bother coming in for my appointment. Needless to say that since I have moved overseas they have delayed my medical records so after 5 months here, I am still waiting for them to show up. I am hoping that all of my documentation is still in there and I may even have to put in for another request since the first one was not complete with all of the paperwork history. I will be praying for your success and hoping all goes well for you.
   — windowoftheteeth

January 13, 2007
I have tricare prime and I was approved in one day. If you meet the requirements, you should also be quickly approved. Call and make sure that they have all the correct information. There may have been a mistake on your form as simple as making you taller than you really are. That can affect your BMI, and they won't approve if you are even .1 under the BMI of 40.
   — Cheriehott

January 13, 2007
Elizabeth, I have more questions than answers. I had an RNY done almost 3 years ago via Tricare, they were excellent. I know the rules changed after I had surgery, but I don't know why they denied you if you qualify. I did have to fight with Tricare about skin removal from my abdomin, and went through 2 appeal processes, and eventually lost. They have up to 90 days to reply an appeal, each time, upto twice appealed. It was not fun, and not helpful. If you qualify, and they have the service, then you should appeal or question their decision, but it is not fast. I will be glad to talk with you more about this, just email to me or visit my page for info. I checked your profile, and there is no info there, but I have quite a bit on my profile if you want to check, and email me with any other questions. I will help if I can, but you can't force them to go quickly, it just does not happen in cases like this. Sorry to dissappoint. Best to you, Patricia P
   — Patricia P

January 13, 2007
Are you currently in one of our armed forces or is it your spouse who served? If you are eligible for VA health care (you should apply if you have not already done so), I recommend that you try to get your bariatric surgery done through them. The VA does happily approve veterans for bariatric surgery if you qualify based upon your physical and mental suitability for the procedure. The VA will subject you to a series of physical tests (upper and lower GI, heart, proctoscopy, etc) as well as an evaluation by a Behavioral Medicine psychologist. If all goes well, you should be approved. Note that I have found that all VA Health Care Systems across the US are NOT created equally. I'm sure it's not supposed to be that way but the reality of it is that there are significant differences in the medical care veterans receive from the different VA Health Care Systems. If you are fortunate to be in the Palo Alto Health Care System (PAHCS), at least relatively close to the PAHCS area of coverage, you are in luck! There is, for example, a different HCS in San Francisco and althey are very good there, rumor has it that the nearby Palo Alto HCS towers above the SF HCS. I believe the greatest reason for the excellence of the PAHCS is its very close association with the Stanford University School of Medicine which is very close by geographically. Many of the interns and resident M.D.s at the Palo Alto Division (PAD) hospital are, or were, Stanford Medical students. The supervising M.D. in the OR for my RNY procedure at PAD (Dr. John Morton) is an experienced bariatric surgeon with a medical group associated with Stanford University. ----- So maybe the discrepancies in medical care for veterans across the VA health care systems holds true for Tri Care as well. If you go to a different Tri Care provider, you may get a more favorable response to your request for bariatric surgery. Also, don't forget that the response you get from someone often has much to do with who it is and what they ate for breakfast that morning. So don't give up and don't take 'NO!' for an answer. If, as I've read in others' responses to your question, Tri Care patients are being approved for bariatric surgery, then you can be approved too. If your application for surgery has been rejected, you have every right to make them justify their action. If they can not justify their rejection and are simply basing their decision on the whims of someone who didn't like what the had for breakfast the morning they read you application, you have solid foundation for appeal and, if necessary, legal action. You may want to seek the services of a professional who is intimate with the ins and outs of Tri Care to help you. Good Luck!!
   — [Deactivated Member]

January 13, 2007
The Va health care is excellent. If you meet all the requirements contact the closest VA they deal with tricare daily. good luck and don't take NO for a answer you can appeal.
   — dolly-420

January 14, 2007
Thank you everyone for all of your support and info. I do meet the 200% of ideal body weight requirement. I am 5'2 and 236 with a BMI of 43.9. I am calling the nurse who has been so great and supportive of everything this whole time. I do not believe that she is aware of the 200% requirement. I went to the tircare representative office and found out that while anyone can see in person that I am a very petite person that if the paperwork dosent say this they will go off of the highest ideal weight for my height. Once this was explained to us (after hours of fighting for this scrap of info) the tricare guy slipped us a number and said that we didnt get it from him. This week is going to be all about battling this thing untill I get an approval. I have gotten such wonderful support here and recomend this site to everyone, I realy wouldnt have been ok without you all. IF tricare gives me attitude we will be headed to the VA as I am a veteran and actualy got kicked out of the Navy due to my weight. We are holding that as a backup plan because the VA medical is hit or miss and I realy dont want to leave this up to chance.
   — lizzieleprechaun

January 15, 2007
I am also going through Tri-Care for my surgery here at Eglin Air Force Base. I was approved the same day because the surgery will be performed by two military docs. I was told at first by my PCM that he did not think I qualified but he filed it for me anyway.I then went to Tri-Care office on base and talked to them face to face.Come to find out, my doc was looking at an old requirement form off his web and the tri care ladies pulled up another requirement form. My doc said my bmi was too low..38.5. The tri care ladies said all I needed was to be 100 pounds over weight and have co-morbid obesity disorders like diabetes, hyper tension, high blood pressure etc. I have type II diabetes..not under control, high cholesterol and a thyroid condition which I have been on meds for 23 years. I have already had my psych eval, nutrition appt,. ultra sound of my arteries because I had a few mini strokes this past summer from the diabetes. I now have an appt with the surgeon again this thursday the 18th of Jan 2007 and I should be given a DATE. You need to talk to tricare in person...if I qualify then you should..good luck. Jan
   — macmom46