I was DENIED by Tricare...Has anyone every appealed?

Startingover! · 04-16-2008, 08:20 AM

I got my letter of denial from Tricare yesterday. Very disappointed. I was wondering if anyone on here had ever appealed with Tricare and if so what was the outcome? Also, I have Tricare Prime, is Tricare Standard easier to get approved with? If it is I'll switch!!

Thanks in advance for any info!

irideaqh · 04-16-2008, 08:31 AM

Did they give you a reason for why they denied you?

SuzanneG · 04-16-2008, 08:34 AM

I got denied with federal BC/BS. Not sure if they would help you, but I'd be happy to share my appeal letters if you need a sample to start from.

tweety63 · 04-16-2008, 08:55 AM

Suzanne
Shared her letter with me and I was banded just last week. I say give it a try it will never hurt.
Colleen

Startingover! · 04-16-2008, 09:08 AM

I called Tricare this morning and they said I was one comorbidity (spelling) short. They did however say that I needed to appeal it and in the appeal make sure the doctor notes, not documents, that I have arthritis in my knees and back. She led me to believe this would get it approved, but I'm still very hesitant about it! I then called the doctor and they had talked with Tricare yesterday about it and were told the reason it was denied was because Tricare doesn't cover it. Which is not true. So the doctor's office is first going to address that issue, if they don't get anywhere with that then we will appeal it with the words "arthritis" in the appeal.

The letter of denial did say that it was not a covered procedure. It also said that it covered vertical banding, which I thought was the same thing as LAP-BAND®. So not knowing this I called Tricare first. But after talking to my doctor's office they said that the denial is strictly because Tricare claims they don't cover it. I'm so confused! I guess I'll just wait to hear back from the doctor's office today after they talk to Tricare.

I've read many things on here about the approval process and what a roller coaster ride it can be. I had no idea! It really wears you down. I only hope it's worth it in the long run.

celticdreamer · 04-16-2008, 09:20 AM

Sorry to hear about your denial and I hope you will appeal.

Vertical gastic banding is a different and more invasive procedure than the LAP-BAND®. It involves some stomach stapling. My friend's wife had this done, so that's how I know.

Best of luck to you!

Startingover! · 04-16-2008, 09:30 AM

Quote:

Originally Posted by SuzanneG

I got denied with federal BC/BS. Not sure if they would help you, but I'd be happy to share my appeal letters if you need a sample to start from.

I will let you know if I need to borrow your appeal letters as a guide. Thank you so much for the offer!

Cadets71 · 04-17-2008, 01:34 PM

TRICARE Now Covers "Lap-Band®" Surgery
Military.com | TRICARE Press Room | January 16, 2008
FALLS CHURCH, VA. - TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band® surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007.
"We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community," said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. "We've added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health."
Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band® surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person's height and bone structure may also indicate morbid obesity.
In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.
Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online. A search for "morbid obesity" goes directly to the correct section.

Soiic,

Call Tricare and give them the above reference. ASK TO SPEAK TO A SUPERVISOR. YOU ARE GETTING BAD INFORMATION AND THAT IS TOTALLY UNACCEPTABLE. You do NOT have to appeal their mistake. Get a Supervisor and arrange to have your Doctor resubmit for approval - kdirectly to that person.

Please let me know what happens. I negotiated these contracts when I was on active duty. It infuriates me that our beneficiaries have these problems!!

Mary

Startingover! · 04-17-2008, 09:50 PM

Quote:

Originally Posted by Cadets71

TRICARE Now Covers "Lap-Band®" Surgery
Military.com | TRICARE Press Room | January 16, 2008
FALLS CHURCH, VA. - TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band® surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007.
"We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community," said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. "We've added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health."
Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band® surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person's height and bone structure may also indicate morbid obesity.
In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.
Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online. A search for "morbid obesity" goes directly to the correct section.

Soiic,

Call Tricare and give them the above reference. ASK TO SPEAK TO A SUPERVISOR. YOU ARE GETTING BAD INFORMATION AND THAT IS TOTALLY UNACCEPTABLE. You do NOT have to appeal their mistake. Get a Supervisor and arrange to have your Doctor resubmit for approval - kdirectly to that person.

Please let me know what happens. I negotiated these contracts when I was on active duty. It infuriates me that our beneficiaries have these problems!!

Mary

Thank you so much for the information. My doctor's office called them yesterday and spoke with a supervisor. They corrected the "not covered" issue and now they just want me to provide proof of one more comorbidity. They said arthritis in my weight bearing joints would be sufficient. So I tracked down some old MRI results that stated I had arthritis in my knee and lower back. So the doctor is sending those tomorrow. The supervisor has given the impression that with this additional information a approval will come. So we'll see. I'll definitely keep you posted.

Thanks again for the info and advice.

alsorl · 04-19-2008, 06:50 PM

I have Tricare Prime too and was approved last week. I believe you must be 100 lbs overweight with one or two co-morbidities or 200lbs overweight with no co-morbidities.Another patient in the surgeons waiting room yesterday also has Tricare Prime and was approved too. From my research on this site, Tricare is one of the easiest and fastest insurance to get approvals from. Mine was approved within hours.Do you meet their criteria?

JudyAnticola · 04-20-2008, 10:36 PM

Does anyone have any experience with approval from CHAMPVA? I am going that route and hope the approval is quick. Just wondering if anyone else has experience with CHAMPVA.

trell · 04-20-2008, 10:58 PM

Hi, Champ/Va will have a cost share. I am prime but I worked in health admin for a while. Approval should be quick and about the same as Tricare except you will have some cost.