Startingover!

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

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.

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!

Thanks for the link. Do you know what frame they go by or does the doctor tell them that? Congrats to you for your band!

The waiting for this is killing me!! Does anyone have a link to the Metropolitan weight charts that they go by? I lost the link and I just wanted to look at it again. I am trying not to get my hopes up, because I'm really afraid they will not approve it. I don't know what I will do if they don't. I guess I'll go back to Weight Watchers and try that, again.

I guess I jumped the gun. My doctor called Tricare today and the denial was on the first submittal, not on the latest one. They had wanted a little more info after the first one. Tricare said it is still in the pending state. So I'm keeping my fingers crossed but not getting my hopes up.

I wasn't aware that I could question them! Duh!! I'll have to do that when I get home from work. Thank you for the info!

I'm waiting to hear back from the doctor's office as to why they denied me. So I guess we'll go from there. It's just very depressing.

I was denied yesterday by Tri-Care. I'm so disappointed. Has anyone else out there been denied by Tri-Care and then approved on appeal? The doctor is of course appealing it, but I just don't think it's going to happen now. So I'm not getting my hopes up. :huh2:

Mindy-I saw my surgeon around the first of February. They submitted my package to Tricare and Tricare requested the sleep study before approval. But the surgeon requested an endoscopy because of the possible hernia. The hernia turned out to be larger than expected. So we're hoping that will help w/the approval. But of course we were expecting a positive sleep study test because I do have the symptoms of it. But I guess not severe enough to show up on the test! So now they will resubmit it to Tricare and see what happens. Galina-thanks for the info. I guess every place does it different. I'll inquire about the cpap test.

Thanks Mindy, I appreciate the support.

I have a large hiatal hernia, degenerative disc disease, I've had 3 knee surgeries w/arthritis. And that's about it. I just don't know if it will be enough without the apnea. I guess I'll find out!

Sorry, I missed the question at first! No, I didn't have the cpap put on during the sleep study.

thanks for everyone's input. My ENT doc gave me the copy of the report and all is said is everything looked fine. It wasn't until I got home that I actually looked at the report. I guess at the bottom it just looks like they didn't complete the report. I guess I'll just wait for my surgeon to look at it. Not that I want to have sleep apnea, but I was a little disappointed that it showed no findings at all. And I know that on an average night I do have the symptoms of apnea. I just hope the insurance will approve my surgery with this report. Thanks again to everyone for their input!

I have copied my sleep study report below. To me it doesn't look complete, but then again I've never seen one before! I was wondering if anyone could help me to understand this? Thanks in advance! SPLIT NIGHT POL YSOMNOGRAPHY POLYSOMNOGRAM TECHNICAL SUMMARY: This is a 16-channeI polysomnogran. Duration of the recordingis 363.0 min. .Four channels are used for EEG, two for oculog'am, and one each for chin EMG, nasal-oral airflow, chest respiratory effort, abdominal respiratory effort, ECG, oxygen saturations, body position, microphoie for snoring, and two for anterior tibialis muscle activity. Lights out at 11:29 PM andlights on at 5:32 AM. POLYSOMNOGRAM SUMMARY: Sleep architecture: Sleep efficiency is 85%. Sleep onset occurred at 10.5 minand REM onset began at 285.0 min. (4.8 hrs.). The patient spent 2% total sleep time inStage 1, 92% total sleep time in Stage 2,0% total sleep time in Stages 3/4, and 5% in Stage REM. Arousal rate is 13.0 per hour. Total sleep time is 310.0 min. (5.2 hrs.). Respiratory data; 0 obstructive apneas, 0 hypopneaSjO mixed apneas, 0 central apneas are noted. The average rate is 0.0 per hour (normal is less than 5). Supine rate is 0.0 per hour with a non-supine rate of 0.0 per hour. The non-REM rate was 0.0 per hour and the REM rate was 0.0 per hour. Minimum oxygen saturation with events is 0. Total supine time is 86.6 min. with anon-supine time of 222.8 min. (3.7 hrs.). Periodic Limb Movements in Sleep: PLMS rate is 0 per hour. PLMS arousal rate is 0 per hour. POLYSOMNOGRAM IMPRESSION: This overnight sleep study reveals the following fhdings: 1. Patient history (Get from the Sleep History Questionnaire) 2. A) The pqtient did not meet laboratory proJoCQlcriteria for initiationof nasal CPAP during the first two hours of the study. Upon completion of the study, the/patient dd qualify for a nasal CPAP titration study. 3. Respiratory Finding^ (AM, Severityv& Saturation) 4. Snoring level: 5. ECG: 6. PLMS: 7. Sleep Architect: 8. Medication effects on steCp (if applicable): 9. Other: CLINICAL RECOMMENDATIONS: 1. Treatment options: A) Normal PSG: Fujtt night CPAP titration study: C) Surgery:

Congrats Zeama!!

It's the Amy part of Steveamy LOL!I was wondering if they will let you take anything to help you sleep or not. I have ambien that I take as needed, I'll have to ask if I can take it because I imagine it being difficult falling asleep hooked up to everything! Thanks for the info!

You know it's really strange my doctor says that I will not have to take any pre-op diet, except for 24 hours before. I'll have to be on a liquid diet then. I thought that was kind of strange. But I'm not going to complain about it!

I am scheduled to have a sleep study for sleep apnea on the 24th. I was wondering if anyone can give me any insight as to what to expect? Thanks in advance!

Thank you so much for everyone's input. Especially those who have also had a hernia repair. It is very useful to hear about other people's experiences. I'm a big baby, but from the sounds of it the surgery is really not that bad.

Ok, I'm reading all of your post and getting really SCARED about fills! Do all these attempts to find the port hurt? Do they give you a local or anything? I know every doctor is different, but now I have a couple of new questions to ask my doctor!!

My doctor also keeps his patients overnight, thank god. That way they can give me whatever is needed for whatever pain I may have!! I guess it will be HELLO morphine for me also! I definitely will think that is all worth it when the weight is off! Thanks for the info!

The nurse asked me how tall I was and not realizing that she wasn't going to measure me I said 5' 5 1/2" (I'm really 5'6"). She just wrote it down and said ok. If I had known that she wasn't going to measure me I would have maybe been 5'4" on that day!! Not to cheat the system or anything, but every little bit helps! I'm just shocked that they don't actually measure you. But I guess in all reality the more people they are able to get approved the better business is for them.

Jaime, Have fun with the EGD, ugh! My psych eval went well on Friday, I felt like I had been put thru the ringer, but I passed. I go tomorrow to see the dietician and pre-op class and then they submit my paperwork to the insurance for approval. So I'm keeping my fingers crossed! At least you know someone else who has used your doctor so you can pick their brain. That should make you feel more comfortable. Keep me posted as to your progress! Amy

Hi everyone, I am also beginning my lap band journey w/Tricare! I have had my referral from my PCM, which Tricare approved in 1 day, I had my consult w/the surgeon, I've had my psych appt and tomorrow I have my dietician appt and my pre-op class. So tomorrow the surgeon will submit my paperwork to Tricare. So I should know something by the end of the week. But the surgeon's office is 100% sure that it will be approved. They are proceeding like it has already been approved, short of giving me a surgery date. I only had my consult w/him last Wednesday, that's how fast it's moving. The surgeon said I should be banded within a month from last weeks meeting. I'm trying not to get too excited until I hear back from Tricare though. One more thing, the surgeon did not require any documentation about any co-morbidities. Which was strange to me. They simply took my word for it. Go figure.