Tricare Prime has denied me

AZArmyWife36 · 07-07-2008, 04:48 PM

So, I just returned from a fun four-day weekend in Vegas! I lost but had a blast with DH. I hadn't been online until this morning and saw that Tricare Prime has denied my approval.

I can't believe how upset I am. I have a 35.6 BMI and have asthma and PCOS. I did a sleep study a week ago but those results haven't come through. My question and I'm hoping for some help is . . . has anyone appealed? Any pointers on how to get APPROVED? All help is greatly appreciated. Sad day for me. Thanks so much! Just me, Brenda B.

Kat56 · 07-07-2008, 05:02 PM

I am so sorry that you didn't get approved for your surgery. I know that you asked for help/advice and I don't know if I am approved yet or not but I did want to reply and let you know that you are in my prayers for an approved appeal.

hugz 2u,
Kat

AZArmyWife36 · 07-07-2008, 05:04 PM

Thanks soo much! I truly appreciate it! Good luck on your journey!

1000words · 07-07-2008, 05:36 PM

From what I have heard about Tricare they are pretty much stuck on the concept that you have to be at least 100 pounds overweight to be approved. Which, I am guessing by your BMI that you are not.

My surgeon's office told me that you either have to be 100 pounds with co-morbidities or 200% of a normal body weight.... and I luckily qualify in both columns. :(

It is really sad that Tricare is unwilling to help until you are basically in pain and unanable to move well... but at least they are better than most insurances.

Good luck.

JenniLeen · 07-07-2008, 05:42 PM

girl all I can say is appeal appeal appeal. Its gonna take alot of hard work on your part, getting letters and things from doctors, but I'd def appeal. Your bmi is high enough with your co-morbs that you should be approved. Call them and talk to them. I know that you are bummed, I'm sad for you too. But hang in there and keep your head high. Everything will fall into it's place. {{BIG HUGS}}

rakes4321 · 07-07-2008, 06:12 PM

Hey, we are Air Force and I had my surgery at Wright Patterson AFB in January. 5 weeks after my surgery, Tricare "Okayed" paying for fills, before that, you were on your own for fills. I am 6 ft and had a BMI of 36. I also have (or had at the time, I just had another sleep study and I don't have it anymore!) sleep apnea and had to be on CPAP. My PCP was a hinderance! She actually told me that the military didn't do that surgery and even if they did, I would n't qualify. So, she wanted to send me to the psych clinic to get meds! So, I pushed for a consult with the endocrinologist, who happened to be friends with the general surgeons that DO do this surgery for the military. I would call the Tricare office and ask them WHY you were denied. The regulation states that your BMI must be at least 35 and have ONE of the three co-morbidities.......Diabetes, High blood pressure, or sleep apnea. I'm not sure, but I think that what you might be running into is the particular facility that you are stationed at. WPAFB only started doing these surgeries in March of the previous year. The surgeon had only dont about 50 or so lapbands when he did mine. There is a fully functioning hospital with emergency room at WP. Before that, you couldn't get it done. I think that you may have to be stationed at or travel to a base that has a hospital. Which, from what I understand, aren't very many, only 3 or 4 in the country. Maybe, like the fills, at a later date, they will give people referals out for the surgery. Before they changed the fill thing, my surgeon said that I could just fly back, because we just PCSed to California, and he would do my fill. So, be encouraged......wait for the results for your sleep test. If that comes back positive, you DO qualify, that is not the issue......it's whether or not they will pay some civilian doc 30,000 to do the same surgery that they can get military docs to do for a lot less. So, I would try to work this angle with tricare..........if I can get to a facility that does the surgery, can I get it done? Hope that helps.
Amy

thatDEgirl · 07-07-2008, 06:14 PM

According to the Tricare printout I have in front of me, you have to be 100 pounds overweight PLUS comorbids or 200% or more of you ideal weight. I wouldn't think a 35.6 would apply!?

mphsmommy · 07-07-2008, 06:18 PM

Yea, with Tricare you have to have a 35 to 40 BMI with 2 or 3 comorbidities (they don't count PCOS) and no comorbidities with a BMI of 40 or more.

JWRN · 07-12-2008, 07:51 AM

I have tricare north and am hoping to get approved. So far they have approved the 7 surgeon's visits. My bmi is at 36 and I have 2 comorbidities (hypertension and sleep apnea on cpap). I would definitely call tricare to see why you were not approved. I do know that every Tricare handbook I have read states the 100 lb overweight or 200% thing. No mention of BMI. But I have heard of some people being a little under the 100 lb overweight limit and still getting approved. Good luck and let us know what is going on!

MJN · 07-12-2008, 10:13 AM

I'm sorry that you were not approved for your surgery. But definitlyy appeal and have your physician seand a lettr of medical necessity and check with your insurance and make sure this is a covered benefit. It will happen for you so hang in there.

clayverde · 07-12-2008, 12:56 PM

Hi - I was really surprised to read your post that Tricare denied you. I am also a Tricare prime (Triwest - Navy wife) and the whole process was a breeze, not even a blip. I'm not trying to rub it in, I'm trying to explain why I was so shocked when I read that you had such difficulties - which I really feel for you. So here is some stuff that might help.

Definitely appeal!!!! I can't stress that enough. And when you do, use some of this for your ammo. Tricare policy to qualify for weight loss surgery is "weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity" They list some examples but they obviously can't list every possibility, so they use the quoted standard. SOO... here is a link to a site that shows the higher incident of mortality, etc with PCOS:

Cardiovascular Risk in PCOS -- Guzick 89 (8): 3694 -- Journal of Clinical Endocrinology & Metabolism

And here is another one that shows a higher rate of mortality for PCOS patients (it also raises serious doubts concerning one of the leading studies that is used to show NO link between PCOS and mortality rates - which is good for you because that is probably the study they would try to use to prove the lack of higher mortality rate and therefore deny you)

Evidence for Association Between Polycystic Ovary Syndrome and Premature Carotid Atherosclerosis in Middle-Aged Women -- Talbott et al. 20 (11): 2414 -- Arteriosclerosis, Thrombosis, and Vascular Biology

The following link is to a study that shows the benefits of weight loss surgery on PCOS - basically it can almost resolve the symptoms. PLUS the study shows that the control group on a strict diet and exercise program were unable to achieve even close to the same results as the weight loss surgery group.

The Polycystic Ovary Syndrome Associated with Morbid Obesity May Resolve after Weight Loss Induced by Bariatric Surgery -- Escobar-Morreale et al. 90 (12): 6364 -- Journal of Clinical Endocrinology & Metabolism

This is a link that shows that people with asthma have a higher mortality rate than the general population:

http://ije.oxfordjournals.org/cgi/reprint/25/3/617.pdf

This is a link to an article discussing a study that shows that obesity makes asthma worse:

Obesity Worsens Impact Of Asthma, Study Shows

This is a link to the actual study that is cited in that article, but you need to be a member to read the whole article, but just having the actual cite to the study is enough for the appeal. If they question the study and want to read the whole thing let them pay to read it.

Dynamic Hyperinflation with Bronchoconstriction: Differences between Obese and Nonobese Women with Asthma -- Sutherland et al. 177 (9): 970 -- American Journal of Respiratory and Critical Care Medicine

And this is a link that shows the marked improvement in asthma after weight los surgery:

Weight-Loss Surgery Patients Improve Asthma, Osteoarthritis

So I don't know if you are 100 lbs overweight or not, but even if you aren't, I would still try to appeal. And the more you can show the significant benefits that can be reaped by the weight loss surgery, the better you are. You have to try and force them to see it economically - it is cheaper for them to pay for the surgery now and then NOT pay for all the long termcare and issues that they would have to pay for if you continue on the path you are now. So now you have a set of studies showing that 1. PCOS has higher mortality rates, 2. PCOS is worsened by obesity and 3. PCOS can be greatly improved with weight loss surgery. And as a back up you have studies that show 1. Asthma patients have higher mortality rates 2. Asthma is worsened by weight loss and 3. Asthma can be significantly improved with weight loss surgery.

That alone may be enough to get them to reverse the denial (but I don't know, I've never done that) but if it were me, I might try to do some research on the net for various costs of complications from PCOS and/or asthma and then compare it to the cost of the surgery. Really drive home the fact that they are actually saving a lot of money by having you be healthy for the rest of your life after this initial investment.

Anyway, I hope any of that helps you - good luck and keep me informed!!

Mommy.ArmyWife · 07-13-2008, 11:02 AM

Quote:

Originally Posted by AZArmyWife36

So, I just returned from a fun four-day weekend in Vegas! I lost but had a blast with DH. I hadn't been online until this morning and saw that Tricare Prime has denied my approval.

I can't believe how upset I am. I have a 35.6 BMI and have asthma and PCOS. I did a sleep study a week ago but those results haven't come through. My question and I'm hoping for some help is . . . has anyone appealed? Any pointers on how to get APPROVED? All help is greatly appreciated. Sad day for me. Thanks so much! Just me, Brenda B.

From what my surgeon told me, you have to have a BMI of 40 (mine was 39.5) or be 100 lbs over weight, or they won't approve. Doesn't matter what else you have, or so my surgeon said. It's stupid, but it is what it is. Luckily even though my BMI wasn't quite 40, I was 100 lbs over weight. I'm sure you can appeal, but I don't know what that process is like. Good luck to you! I know all these insurance hoops you have to jump are so frusterating! I've even heard of people GAINING weight just to be approved, and it's sad that insurance requirements have brought people to that! I really hope you get approved!

armywife4life · 07-13-2008, 11:32 AM

Appeal Appeal Appeal don't give up girl!!

JWRN · 07-13-2008, 01:15 PM

It is important that your surgeon knows what your insurance is looking for and how to word it. Some offices have never dealt with tricare before. Call tricare Monday morning and find out why you were denied. Then you can go from there. Let me know what you find out, as I am trying to get approved also.

azairforcewife · 07-30-2008, 02:15 AM

denied

i have tricare and the dr office sent everything in yesterday and today i went on the web site and it said denied. i am 236 and 5'4 and thats 100 pds overweight by the met life charts and i have thyroid and pre diabedic!!! im so bummrd im calling in the morning for a reason any body else have them change approval after calling ?