Hey everyone, I have tricare west prime and I went through everything that they wanted me to and got approved for everything except the surgery. I'm a bit confused and a little pissed off at the same time. why would they go through and approve everything but deny the surgery???has this happened to anyone else? and if so what did you have to do about it to get them to approve it? Thanks a bunch

Do you meet the criteria that they require? Do you have one of the co-morbidities as well as 100+ overweight? My surgeon said that Tricare is usually one of the easiest to deal with.

I was denied by Tricare too. I felt the same way too very disappointed and upset that I went through the whole process to get denied. My surgeon submitted the appeal on my behalf so now I wait again...

I'm sorry ya'll are having problems with Tricare. I guess each one is different. I have Tricare Reserve Select. They faxed my paperwork into Tricare Friday late afternoon and they approved Monday afternoon. I am currently 108 lbs over ideal body weight and have a BMI of 41.2. The coordinator said that helped the approval process. I also had to write a letter to Tricare basically pleading with them to approve me. Don't give up, just keep on giving them what they are asking for and they will approve it eventually. My surgery is scheduled for May 25th. Good luck!!

I have tricare PRIME also and I was afraid that I would get denied after they told me at my consult that I had to be 100+ pounds with one co-morbity. I was pretty depressed and did some research. Tricare uses the METLIFE weight & height chart and they go by the smallest weight on 'default' MEDIUM frame. By that, my ideal weight is 102lbs (medium frame). okay okay please dont judge me but I am originally 4'8 but slouched and bent my knees a little during my consult and they got me at 4'6...which makes it easier for me to weigh more. ANYWAY.....obviously 4'6 or 4'8 is considered a small frame so why would they use the medium frame??? If they used the small frame my ideal weight for my height is 79lbs. I clocked in at 180 so I made sure that my dr put on the referral that i was a SMALL frame...i got APPROVED and is super stoked!! Monday i will schedule my pre-op appt and will ask for the 2nd week of june for my surgery! wish me luck!!

Tri-West denied my lap band adustment (fill at doctors office) stating it is a Non-Benefit...has anyone else had this problem, if so how did you resolve it?

Hey everyone, I have tricare west prime and I went through everything that they wanted me to and got approved for everything except the surgery. I'm a bit confused and a little pissed off at the same time. why would they go through and approve everything but deny the surgery???has this happened to anyone else? and if so what did you have to do about it to get them to approve it? Thanks a bunch

Tri-West denied my lap band adustment (fill at doctors office) stating it is a Non-Benefit...has anyone else had this problem, if so how did you resolve it?

Tri-West denied my lap band adustment (fill at doctors office) stating it is a Non-Benefit...has anyone else had this problem, if so how did you resolve it?

How long ago were you banded? Did Tricare pay for your band? If they did, and if it's been more than a year or so, maybe have your doctor's insurance coordinator resubmit the claim, citing the band surgery dates you had. Tricare should have to accept the fill if they paid for the surgery, too. That's like buying a car and not being allowed to put gas in it.... I was banded in December, and Tricare is paying for my fills, no problem.

Good luck!

Dave

Tri-West denied my lap band adustment (fill at doctors office) stating it is a Non-Benefit...has anyone else had this problem, if so how did you resolve it?

I am covered for 3 months of fills/appts post-op, but then I will pay $175 for a year of follow up appts.

It is covered in Standard with a huge co-pay...my practice covers approximately $375 of the $500 fee. I suspect your office is not coding properly because Tricare is tricare with no differences between N, E. S, W. Ask them to resubmit with different coding.

Mimi

I have tricare prime too, I'm in San Diego right now. I'm SO worried after reading all the posts about denials from insurance. I am aware of the requirements tricare has in place, but I'm not sure yet if I have any comorbidities. (my first appointment is next Friday) I am 5'6 and 240 pounds. So I think a barely make the 100 pounds over thing. If anyone has any advice on dealing with PCMs and how to make sure I get approved and so on, I would really like the help.