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:

Tricare doesn't require anything except that you meet the weight requirement, however, some surgeons require different things. Such as psych visit, nutritionist, etc.

I just got denied by Tricare today as well. I am so bummed. They told the Dr. office that I did not meet THEIR co-morbs. I have mild sleep apnea, fatty liver disease, high cholesterol, GERD, and arthritis in my knees...

I would diffentaility appeal it, I did and got approved!!!! But I had bcbsf Il. It's worth a try.

Hi, tricare has to deny somebody, I guess they do not want it to appear they will approve everybody the first time. I would definitely appeal it, they will approve in the appeal. I used to work with them.

I just got denied by Tricare today as well. I am so bummed. They told the Dr. office that I did not meet THEIR co-morbs. I have mild sleep apnea, fatty liver disease, high cholesterol, GERD, and arthritis in my knees...

Are you planning on appealing it? If so what is the status of yours? I'm waiting to hear back on the appeal. They told me to call back on May 6th. The waiting is killing me!! Good luck to you!

Hi, tricare has to deny somebody, I guess they do not want it to appear they will approve everybody the first time. I would definitely appeal it, they will approve in the appeal. I used to work with them.

This was the second time it was denied. The first time they wanted more information, a sleep study done etc. So we gave them the updated info and they denied it. So they wanted more info, so now we're waiting to hear back since we sent them even more info.

Considering that you use to work there can you give us any insider advice?? LOL

I'm in the process of being approved by tricare too...did they require you to do a 6 month supervised diet?

Good luck and TIA

No, Tricare does not require a 6 month supervised diet. At least not to my knowledge.

I was told (December 07) they would require BOTH 6 month diet and 6 month phyc evaluation. They did approve bypass right away. Here at San Diego they apparently just started doing lap-band at Balboa Hospital. I opted to self pay with a MORE EXPERIENCED doctor over jumping through the Tricare hoops olny to get a LESS experienced surgeon there.

I am probaby putting myself in a bad place here but I am gonna give some information that I thought may be helpful to those of you who have not yet been approved by your insurance companies. I am a registered nurse and just banded on 4/28. I also work for an insurance company in the pre-certification area. I have worked for 2 different companies and have found from both that the criteria seems to be similar. Believe it or not, and I am sure most of you won't, the insurance company is not against you having the surgery. They do however want you to be successful and s such they do usually have some strict guidelines.

First you have to meet weight requirements that are set by the National Institute of Health, not by the insurance companies themselves. For most companies (and some still only cover he gastric bypass, and do not find the lap band acceptable) they require you to have a BMI of 40 or more or 35 or more with SIGNIFICANT comorbidities. SIGNIFICANT comorbidities include uncontrolled diabetes, uncntrolled hypertension or heart or lung disorders that are adversly affected by being overweight. Your insurance company should be able to give you a full list of the conditions that they consider to be significant conditions.

Next companies require that you are involved with a multidisciplinary plan. The reason for this is that they want to know that the doctor that performs your surgery is skilled in the procedure and has been successful with the surgeries in the past. Then they require that you have had nutrition and psychiaric evals to ensure that you are prepared emotionally and diet wise for the significant changes that you will be undergoing after surgery. Yes, most of us have some level of depression but if you are feeling suicidal or you have problems relating to reality you would need to get this treated before considering surgery.

Next is the weight loss pre-op. Many people question why they must lose weight before surgery when it haas been the inability to lose weight that has brought them to this point. Well, there are a couple reasons for this. First the pre=op diet varies from doctor to doctor but in general they want to see that you can handle significant changes in your eating prior to surgery. Next they need to shrink your liver and other organs that may be in front of your stomach so thy can see your stomach clearly for your surgery. Then of course, the fact that we are all obese going in we are significant surgical risks and weight loss does help lesson the risk of complications following our surgeries.

Some companies have upper limits of BMI for the lap band and that is based on the fact that studies have shown that people who are very large do better with the bypass.

All companies are required to provide you with the criteria they use to make a determination so if you are in doubt call your member services and ask for their bariatric surgery criteria. They can give this to you so you know exactly what is required and you can be sure you have done all you need to do before submitting your case for approval. If you have met all the criteria and you are denied then appealing the decision is your best option. The company does need to provide you with a rationale as to why you are denied and if you can prove that their reason is false then you should have no problem getting a denial overturned.

I hope this helps. Good luck to all,:smile::thumbup:

Tricare only goes by the weight requirements and co-morbs. I only had HBP, high blood pressure and joint pain. I have read on other threads that they were approved automatically because they were 200% overwweight according to the weight requirements. If you meet the requirements and you have no other health conditions that seem threatening to the surgery, then you should be approved. Is there a reason why they are not approving? What exactly are they saying that they need?

Tricare only goes by the weight requirements and co-morbs. I only had HBP, high blood pressure and joint pain. I have read on other threads that they were approved automatically because they were 200% overwweight according to the weight requirements. If you meet the requirements and you have no other health conditions that seem threatening to the surgery, then you should be approved. Is there a reason why they are not approving? What exactly are they saying that they need?

I am exactly 99lbs overweight. I would hope they would over look the one pound! I have documented via MRI's arthritis in my knees and back. Have had 3 surgeries on my knees. I was tested for sleep apnea which was so mild it was almost negative, but they did request further testing. I have a very large hiatal hernia. Shortness of breath, various documented weight loss attempts by doctors. I've passed all the required psych tests, nutritional tests etc. I think there are a few more mild co-morbs.

I actually just got off the phone with Tricare. They said that the when the doctor sent in the last updated clinicals they didn't send in a letter of appeal, so they are not processing it without that letter. But they said that I could send the letter. Which I just did and have received receipt that they received it. So maybe now the ball with start rolling!!

Thank you for everyone's information. It is very, very helpful!

Hi, it is hard to say at this point, but if you are 99lbs overweight, they just might deny you because you are not 100lbs over. It is according to who recieves your claim, if they are a stickler to the rules, they may not approve it. However, if it is someone who is more free hearted, they may say 1lb does not matter. Don't magnify the knee surgeries too much because they may feel that your wieght is not contributing to the knee or joint pain. Just say you have joint pain. I know it sounds small, but that is the way insurance companies look at stuff so they can deny it. Were you 99lbs overweight when you had the knee surgery? Did tricare pay for the knee surgeries? Mild sleep apnea may not fit the co-morb, I thought it said severe in the policy manual, I will check. Do you have high blood pressure at all? It will probably be up after this ordeal. I actually did the appeals for the hospitals. I would find loops or gaps in why they denied claims and would have the billers to fix the claim and then resend it with an appeal letter. I worked with BCBS and Tricare and many more.