Question:
Please, can anyone help me with appeal? I was denied by Tricare Prime.
I would like any advice from anyone who has won an appeal through Tricare. How did you go about it? What did you include in your letter etc? I am 5'3" and currently weight 240. I am working on the appeal letter and could use some help.Thanks. — Jillisa R. (posted on January 20, 2004)
January 20, 2004
I dont know why you were not approved your BMI is over 40. Are you
overseas, if you are Wilford Hall in San Antonio will medivac you to have
the surgery you can contact Mrs Keyes.. I dont have the number off hand but
I know alot of people overseas comings to Wilford Hall to have surgery
they have an excellent program.
— Catherine B
January 20, 2004
I don't understand why you were denied by Tricare Prime. I was approved
within one day, and everyone that I know that has Tricare Prime and had WLS
was approved. You need to make sure that your surgeon sent in the correct
codes, or that your surgeon is in the Tricare Prime network, or that your
enrolled correctly. If you choose a surgeon that is out of network, you
diffently would be denied, and there is no reason to appeal it. You need
to call Tricare and find out why you were denied. If the surgeon put in
the wrong codes, give them a call and have them resubmit with the correct
codes. If your surgeon is out of network, find or ask Tricare which
surgeons you can go to. If WLS is medically necessary, and you have a BMI
of 40 or more, and co-mobilities, you should get approval. This is the
rest of your life, and Tricare Prime is excellent insurance, be pro-active,
do some research, make some phone calls, do not go for a appeal, with
nothing changed, you will be denied again. Hope this helps
— cindy
January 20, 2004
I used a lawyer after a denial. I was fed up. Email gary viscio at
[email protected] He's my saviour.
— superellen
January 20, 2004
I am not sure why you were denied. We have nearly the same starting weight
and height. Make sure that you have the diet history listed along with ANY
co-morbs that you have. And as far as being denied for going out of
network that is not true as my surgeon was out of network and I was
approved with no problem. Email me if you have any questions. Good luck
— Vegas_ T.
January 20, 2004
I also have Tricare Prime Region 1, and I was denied last week. I just got
my letter, and I am sending in my appeal packet tomorrow via Priority Mail.
My BMI is 53.2, I weigh 350lbs and I am 5'8. I was denied due to not
having at least 6 months of supervised dieting by a doctor. What I put in
my appeal packet was a letter I wrote myself basically describing the diets
and weights i have had from age 12 until now, and how my life is
limited..etc..(I can email you a copy if you'd like)..I also included,
AGAIN my nutrition visits (copies from my nutritionist), my psych eval,
copies of prior doc visits from the past year showing my recorded weights,
and highlighted if weight was discussed. In my denial letter it diagnosed
me as being severly obese...HELLOO My BMI is 52.3, I am SUPER OBESE, which
surpasses morbid obesity! I also included a print out from the NIH where
it states the guidelines for who should be approved for the surgery. I
have put this in God's hands....That's all you can do.
— deivaasmom
January 20, 2004
I agree with the other posters. Tricare Prime approved my WLS within one
week and also just approved the lower body lift. SO, that said, let us
know WHY you were denied and maybe we can give you some insight as to how
to proceed.
— Vicki S.
January 20, 2004
i have region 1 also. the best thing you can do is use tricare's own
handbook against them. if you go online on the tricare site and print out
the requirements it is plain. by your height and weight you DO qualify. if
you are sending off a letter i would print out the tricare page and attach
it to your letter. you more than qualify for wls. when you go to the
tricare site search the word obesity and the info you need will be there.
remember you pay for tricare prime.....they can't sell you something that
they claim to pay for(if you qualify)and then not pay for it. if you need
anymore help please email me
— franbvan
January 21, 2004
Thank You all for your responses. I just saw my PCM today, regarding the
denial. I was denied for "lack of qualifying cormorbidies" I
have comorbids but I guess not the "qualifying" ones. My PCM has
referred me to have a sleep study done, I may have sleep apnea. I am
getting very frustrated with Tricare. I meet their 200% over ideal body
weight criteria. Right? The doc said Tricare uses MetLife's scale to
determine what "ideal" should be for height and weight.All I know
is people with BMI's of 38 with no comorbids are getting surgery, and here
I am over that and can't seem to get anywhere. Thank You all for your
support and answering my question.
— Jillisa R.
January 22, 2004
This was my letter. Hope it helps. Good Luck.
April 22, 2002
I am asking for your assistance in obtaining weight-loss surgery. It is
difficult and embarrassing for me to come to you asking for your help, yet
I know and feel that my health has and continues to deteriorate because of
my obesity. I have tried many weight-loss plans, including cabbage soup
diet (lost 40, regained 50), vegetables only /no meat (lost 70, gained 90),
Slimfast (lost 45, regained 55) and may more diets that I did not loose
substantial weight with. I have been to see a nutritionist and have tried
the suggestions she made. I have gained and lost hundreds of pound, but
can not seem to keep the weight off.
I started taking blood pressure medication in August 2001 and at this time
my blood pressure is under control. I am embarrassed about my weight. I
do not go into the clinic with conditions because they are a result of my
weight. As a child I broke my right ankle. The more weight I put on the
more my ankle swells and hurts. Some days it is impossible to walk on. My
back hurts on most days and in the morning it is very difficult for me to
move. As my weight has increased, it has become harder for me to get good
nights sleep. I used to love to walk and would walk with my children
almost every night. Now that my weight is approaching 300 pounds, I can
not even make it around the block with them because my back and ankle hurt.
I have difficulty breathing when I walk.
I have researched bariatric surgery in depth and I am well informed. I know
there are risks associated with gastric bypass surgery, just as there are
risks associated with any surgery. I realize that a lifestyle change and
exercise are major components of bariatric surgery and I have already
started making those changes. Bariatric surgery is a proven method of
achieving long-term weight control for the morbidly obese. Bariatric
surgery is not a cosmetic procedure. I understand that the success of
surgical treatment begins with the patient setting realistic goals and
progresses through the surgery and lifelong follow-up by the bariatric
surgeon.
Prevention of secondary complications of morbid obesity is an important
goal of management. Therefore, the option of surgical treatment is a
rational one. Morbid obesity is a disease, not a disorder of willpower. The
physiologic, biochemical and genetic evidence is overwhelming that
clinically morbid obesity is a complex disorder. Contributing causes are
inheritance, environmental, cultural, socioeconomic and psychological.
— Kimberly V.
January 22, 2004
Kimberly. Check out my profile, down at the bottom is a link to what
Tricare's rules are about WLS. This is not exclusive to Tricare Prime,
Tricare Standard, etc...this is for Tricare period. Last but not least,
call Tricare! They have been so helpful to me! Oh, they will not pay for
a Dr. to refer you to a surgeon. They do not cover any non surgical weight
loss issues. Good Luck
— Carol S.
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