F!@#$%6 tricare prime south (prepare for rant) - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

fochaux · 12-27-2007, 12:52 AM

I've actually ended up retaining legal representation in order to secure an approval for my surgery. I am 5'9" and weigh 272. I have 3 associated comorbidities (diabetes, cholecystitis, arthritis of the weight bearing joints) as well as having had two mini-storkes that both the cardiologist and neurologists have determined were likely caused by my morbid obesity. The weight range as dictated by the most recent metlife table for my height and frame size is 129-142lbs.

To all who have posted about tricare's requirements:

Tricare cannot deny your referral for the surgery unless the reasons for denial are specifically listed in their published policy for gastric bypass.

I have been denied twice stating that:

I have not proven I have been morbidly obese for at least three years. (not in policy and yes I have been....if they would have looked at my medical record which they clearly have access to they would have seen this)

I have apparently not participated in at least a three-month medically supervised diet (not in policy and yes I have....my military PCM counsels me each and every time on diet and exercise and I've been to classes offered by our base nutritionist and have had private appointments with her and have been attempting to follow a medically dictated diabetic diet for well over 3 years now....I also get ripped apart by 3 specialists and my pcm all of whom I see at least once every two-three weeks)

I have not proven satisfactory hepatic, endocrine and liver function (see above....also not in policy....i have a moderately fatty liver. i have kidney stones due to weight related issues. my endocrine function is screwed because i am diabetic and have PCOS....this is contradictory in and of itself because diabetes is an accepted comorbidity with the 100lbs over thing. how can they deny me when they require i have endocrine dysfunction??)

Well no crap to tons of this stuff!!!!!!! I personally feel that Tricare is signing an early death warrant for me! The insurance coordinator and surgeon have both personally called the Tricare (we are in AF at Sheppard so in the South) to see what the deal is. No one and I mean NO ONE with Tricare Prime has been held to even anywhere near the same standard as me and both said this was highly unusual. A third party physician reviewer was brought in on the initial referral and NO ONE will tell me who even put in for the review. I did not give my permission for such a review by an outside party as is dictated has to occur with privacy laws.

i also do not have sleep apnea but have restriction of my upper airwary that results in moderate hypopnia during sleep....in other words it's like pre-sleep apnea.

I let the appeal time frame expire in order to give diet and exercise one last try and now have had my request submitted as a new referral.

I have been going through this process for a little over a year now and am completely flustered!

sorry for the rant. hopefully i'll have good news by friday as I've submitted my medical record since I've been born to Tricare now....well they can't use the excuse they don't have everything in order to process the referral appropriately

katzz87 · 12-27-2007, 01:41 PM

Yikes! Sorry for ALL the frustration! I'm wishing you luck (and crossing my fingers) that on Friday finally get a go-ahead for this surgery.

Cathy

crzymom04 · 12-27-2007, 02:26 PM

dang I am so sorry for you, I will keep you in my prayers, and hope everything works out for you.

bubbasmama · 12-27-2007, 02:34 PM

I found that with Tricare as well as many others you need to have very knowledgble staff sending in your information because it has to be worded perfectly.I am 5'7" and was 263 diabetes and was approved in 72 hours.Barb

Raingirl33 · 12-28-2007, 06:48 AM

I am so sorry to hear of your frustration with Tricare , I have tricare and was approved and had surgery with in a month and a half of being ref. from my pcm. Have you seen a nutrionist through tricare , I had all mine done at the Naval Hospital and they had everyone there I needed to get everything done , even a sleep study center. If you PM me I will give you my contact at the Bariatric Clinic ( she is amazing ) and maybe she can point you in the right direction . She is over the Bariatric Clinic at the Naval Hospital San Diego . If I can answer any questions or be of any assistance please let me know

Barbara

SueRN · 01-02-2008, 10:34 AM

If you want this bad enough, keep up the fight! I had to go thru a 6 month supervised diet....again because the previous 5 I had done had not been done in the previous 2 years. I'm not sticking up for Tricare, but as a nurse reviewer for stuff like gastric bypass for BCBSNC, I have seen some very sloppy MD notes. Actually, some of the poor documentation that I have seen should make these doctors embarassed. It's not that the care was poor, but what was done or discussed was not written down or dictated. I don't know if this is the case in your situation. Don't give up. You will get it approved eventually. Try to be positive as everything happens for a reason. Start making some of the changes now with eating habits. Start a walking program. Dropping some weight and getting in better shape will help to decrease risk for post op complications. I'm sorry it's a struggle for you to get this approved. It's well worth the fight. Keep us posted on your progress. Sue

coptergirl · 01-02-2008, 04:52 PM

Keep on being the squeeky wheel - only you can be an advocate for your own health. You have done great so far with getting all of your facts and records strait, and I encourage you to press on. It does get frustrating, but it is so worth the wait. Hang in there

fochaux · 01-19-2008, 09:27 PM

I've finally gotten approved! My surgery is scheduled for 1/30/08

mommy_to_two · 01-21-2008, 07:13 AM

Congrats!! Good luck with the surgery! I am going through the pre-op process now. I am in the 4th month of my 6 month supervised diet. Hopefully I will get an approval in a few months too. Keep up informed of your journey!!