lydia333

Tricare Denial Questions

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hello, I'm on my way getting stuff ready for my approval from tricare. i was wondering what things would they deny me for surgery. i'm 254 and 5'7. my bmi is 39.8 i have no co-morbidablities. but do have a family history of obesity,high blood pressure, and diabetes. i had been seeing a tricare approved nutritionist since may 2011-nov 2011 til i got my referral. so do you think i will get the final approval? if not what else do i have to do aside from the usual psych eve, blood test, seminar.

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If I remember correctly with a BMI of 39 to 35 you must have co-morbidities or 40 plus BMI.

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yeah my weight has been changing back and forth my official bmi was 41 something. i asked if i lost weight if that would make a difference and they said no that after my official weigh in if i lost weight it wouldn't matter.

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I'm going to keep my fingers crossed for you!!!

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Here is a link to the updated (as of 17/8/2011) policy manual for weight loss surgery. It is good to know their exact verbiage in case you need to appeal.

It does say you need specific co-morbidities, but if you get denied, don't give up! Work with your surgeon's office to file an appeal, if needed, as they'll have a wealth of information from being denied for other patients. But always follow up!

Also, as a heads up, if you don't have enough documented (as in you were seeing a doctor) weight loss attempts, Tricare has been requiring a 6 months medically supervised diet. It does NOT say this in their policy manual, but it started happening end of last year to quite a few people. Not everyone has had to and if you do, while it sucks to wait, I've found it really helps in getting better prepared mentally and physically for the upcoming surgery.

Good luck and try to stay positive, k? :)

Edited by cass2277

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thanks guys! yeah the diet thing has me worried. i did have however have a nutritionist so I'm hoping that will follow under the diet part because it was supervised and documented. i did get lucky in the fact the my nutritionist is also the after surgery and seminar nutritionist. but thank ya'll for every piece of advice.

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I have tricare and was approved within hours. When I started my BMI was not 40 because my weight goes up and down so much. So I actually gained weight (yes I know horrible to gain weight on purpose) but I did it because I am ready for the roller coaster to stop! I would hoover around a 40bmi but not quite there. I didn't have any co morbs but it was a matter of time. I have a family history of heart disease, stroke, high blood pressure, and every one of my grandparents died of cancer. I did everything that my dr asked and I didn't have to show a 6 month weight loss attempt. I started my process on 12/2 and my surgery date is set to 02/27. I actually had the whole month of Dec where I was not able to get anything done such as the phys eval due to the holidays. I checked Monday and there was no request for the surgery via Tricare. I called the drs office and asked if they had sent it and she said yea but would call tricare. Tuesday morning I logged on the tricare website and seen the request and it was in pending status. I was freaking the whole day and nervous! I checked back a few hours later and it was approved! So within hours of the request it was approved! I have seen some people get denied though, none of them knew the reasons but maybe my story will give you a bit of hope! PS I never trusted them going by my first weigh in. I continued to make sure it was over 40 until I got my approval!

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yeah lately i haven't been able to make it go under 40. like you i have had family members with weight related problems such as high blood pressure and diabetes. even a few of my family members has had weight loss surgery and so far they have kept it off. i'm starting to realize tricare doesn't call you back. we'll for me i have been having trouble getting info. i had to call tricare to find out about my referral because they never called me.

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I'm glad I read this. My surgeon's office just started taking Tricare in August of 2011 and since I'm not near a military base, I will possibly be their first Tricare patient. My surgeon has done over 3000 WLSs and they couldn't tell me if I would need to do the 6 month supervised diet or not. I don't have six months of a medically supervised diet, but I do have six months of working with a personal trainer who recorded my weight every week and kept my food journals and my doctor noted in my medical record that I had lost weight due to working out with a personal trainer. Right now my BMI is between 47 and 48.4 and I have high blood pressure and sleep apnea. I'm hoping Tricare won't give me the run around either.

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Good luck for those going up for authorizations! It seems like it is all up in the air as to who has to do the 6 months and who doesn't, so the best you can do is cross your fingers. Not that the 6 months has been a bad thing, but it is frustrating since most of us have been there, done that already.

Again, GOOD LUCK!!!!

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Hello I did everything Tricare asked and have all my paper work in order,my doctor office put 4 different codes on my request and I was denied. Does anyone know if my doctor office fix their issue,will I still have to do an appeal and wait 90 days? PLEASE HELP....MY SURGERY IS SCHEDULED FOR TUESDAY. My husband has already scheduled days off work and I own a hair salon and have informed and scheduled my clients for 3 weeks out. This is really dissappointing.

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If you don't mind me asking, what was the reason you were denied? My surgeon's office should be submitting to tricare for approval this week. Did your surgeon submit all four codes at once for approval? My surgeon's office said they wouldn't submit for anything they knew wouldn't get approved and they dont schedule surgery until after insurance approval. I'm crossing my fingers for your approval.

edited to change the "would submit" to "wouldN'T submit"

Edited by pokememon

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Hi,yes they did. They submitted 43644,43842,43846, and 43848. I did EVERYTHING else smooth saling wit no problems. I was so excited and ready to go and when i got that news it was like my heart stopped. I pray they can do something tomorrow and Im still able to have my surgery tuesday. My only problem is tricare does not ave the reason I was denied on my paperwork. That's what as me worried.

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In July of last year TriCare changed it requirements for the surgery. If you have any comorbidaties your BMI can be as low as 35. You no longer have to be a hundred pounds over weight. I was approved in a couple of days and my BMI was 37 but I did have a few major health issue.

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My BMI is 41 and I have comorbidaties. I've had 2 back surgeries and I'm a hairstylist of 23 years,bc of my back I had to apply for disabilityinwhich that was denied. I really need to work bc I have two daughters in college and disability is no money. I can't continue to woke in this condition and every week Im having to take steroids orally or steroid injections and that's adding more and more weight. I also have hypertention,CRONIC acid reflux along with the CRONIC back pain. Im just so disappointed,when my husband was fighting for our country he had no say so in that (wasn't optional) and he just returned home after is 3rd deployment and Tricare just deny me with no listed reason... CRAZY!!!!!

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That last code looks like the code for a WLS revision. You may have been denied because unless it is a revision from the lap band, it wouldn't apply to you. At first I thought maybe it was because of the multiple codes in and of itself, but it may have just been because that one code was submitted. I'm surprised it was even submitted, but hopefully, your surgeon's office will be able to correct it tomorrow. Good luck to you!

Edited by pokememon

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Last year, March 2011 I was denied. My BMI was 38 with several comorbidties.

My nurse called tricare and they said I was 2# underweight.

I drove in a downpour back to my surgeon's office an hour away for a new weigh in the day I was denied. I was sick to my stomach over it!

I was on my menstral cycle and new my weight would be higher. I drank so much water I could barely walk for that weigh in.

It was approved.

So stupid.

For me, tricare approved my hernia repair, but not the GBP. No way in heck was I going to go through that major operation without fringe benifits of the GBP!

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Hi Paula, How long did it take tricare to come back with a decision for you once your info was submitted?

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Hi all,finally found out the truth for my denial. I had a lapbad placed in January 2010 in which my FIANCE and I paid for. Later that year in July has some issues and found out my gallbladder was a monster and had to have that removed. Keep in mind I was not marriad to my husband and DID NOT HAVE TRICARE. During the gallbladder surgery my lapband was nicked and that caused a slippage, so from July 2010 until may 2011 I walked around sick bc if a slipped band and had to finally have it removed. At this time I was married to my WONDERFUL husband and had tricare but bc they didn't place the band they WOULDN'T pay to remove it, so once again WE HAD TO PAY FOR THIS SURGERY OUT OF OUR POCKETS. Well Tricare denied me for the Roux-en-Y bc THEY THOUGHT THEY PAID FOR MY LAPBAND SURGERY!!!!!!!!!!!! Yes you read it right THEY THOUGHT THEY PAID....ROFLMBO....... Now they asked me to send the appeal along with my receipt and then they will APPROVE MY SURGERY.Are you serious???? All they ad to do was look and see that I had no claim nor referral approval for a lapband. That just goes to show that everybody don't need a job if they are not going to do the job. All of this bc the didn't read their own notes. Now I have to wait for a whole new date for surgery and reschedule time off from my job. I am a salon owner so I have to mess my clients schedule up all over again...UGH!!!!! Thanks TRICARE!!!!!! Sorry It so much but I had to tell yall my whole story.

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Hi Paula, How long did it take tricare to come back with a decision for you once your info was submitted?

My nurse faxed the new request and they approved it within a day or two. I had also written an appeal letter during my denial week. Funny thing is, they approved the new weigh-in information from my doctor's office, but then a few weeks later I got a denial letter from my personal appeal. That denial I disguarded althought it scared the heck out of me. There are so many departments and clearly they didn't all sync.

Really so inefficient.

So this is how it went.

Denial based on 2 pounds too light

resubmit from office

Appeal from me.

Approved from office resubmittal

Denial from my appeal after it was already approved

Try to understand that!

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Hi Paula,have your srgery been scheduled yet? If so when are you having it and how long was your appeal process?

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Hi Paula,have your srgery been scheduled yet? If so when are you having it and how long was your appeal process?

I am all done with surgery. I will be one year out in about a month:) My appeal went very fast. Just a matter of a fax, review and fax back to the office. That particular week tricare was efficient.

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i so totally feel like crying. i was denied today because of a 6 month issue..the new revision as of 10, 2011 doesn't require it..i feel so sick to my stomach..i don't feel good at all..

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My paper work was submitted on a Monday and I was approved on Thursday. I had the Drs office submit the changes to the policy with my paper work. I printed a copy of the tricare changes off the web. Everything went off without a hitch. Weight at approval 197, bmi 37.

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