I GOT MY DENIAL LETTER TWO DAYS AFTER THE DOCTOR SUMMITTED 93 PAGES OF INFO .I'M GOING TO APPEAL BECAUSE I'M 5'4' 236PDS AND HAVE THYROID AND DIABEITES SO I SHOULD HAVE MET THE CRITERIA ANY IDEAS ON WHAT I SHOULD BUT IN MY LETTER. ANYBODY HAVE ANY GOOD RESULTS WITH THEIR APPEALS?:teeth_smile:

I don't know what to do or where to start, would you please share your appeal letters with me so I can have a good place to start. I would really appreciate it. I am just so frustrated & want to scream! I have weighed up to 337Lbs in my life, I lost 200 Lbs the last time, but can't keep it off and I am on the up hill. I have gained 90Lbs in the last 12 mo. I don't want to be at 300Lbs by mid-summer, & the yo-yo dieting has wrecked my body. Why can't Tricare see this? Thanks for your help.

Yvonne:confused:

I don't know what to do or where to start, would you please share your appeal letters with me, so I can have a good place to start. I would really appreciate it. I am just so frustrated & want to scream! I have weighed up to 337 Lbs in my life, I lost 200 Lbs this last time, but can't keep it off, & the yo-yo dieting has wrecked my body. Why can't Tricare see this? Thanks for your help.

Yvonne

Hello,

I also have tricare, and was approved and had surgery may 4, 09. didnt have to appeal. I did have to gain a little weight to meet there requirments, because it stated the requirements in the info i read up on tricare. here's my email address sapphire12305@yahoo.com send me a email and i can forward those appeal letters i got from someone on here, i hope i still have them. good luck!

Is their any way you can send me some appeal letters I was denied:( Thanks in advance

Belinda "carl3024"

yes send me a email mentioning appeal letters, i'll send you the ones i got from someone. sapphire12305@yahoo.com

Can someone please send me some appeal letter...I have been pending with tricare and I want to be prepared if I have to appeal my email address is bajanbk69@hotmail.com

Some insurance companies will deny almost automatically. I think there is a significant number of people who will just accept itand go away. When it is appealed it seems there is a high rate of turn-around. Having a hernia to repair is a good co-morbidity. Also any little thing...pains in knees, occaisional sciatica, stress incontinence...all thejoys of being overweight. Is your BP ok? Good luck!

i am in the same situation with you!!

I would love to have you e-mail your appeal letters: funfabfitfam@gmail.com. I am in the battle of denial!!

Thank you

I was 5'4.5" and 225 and denied the first time through. I appealed and was approved.

I've shared my letters with anyone who asks and so far, based on those who kept in touch, they all got approved.

I would be happy to share my letters. Just PM me with your email address and I'll shoot them out to you.

Hi Suzanne, I was recently denied for surgery on July 2nd due to not enough medical need. I am 5'4 and weigh 232lbs. I am in need of help with the denial letter. Can you send me what you have? my email is roshunda.hamilton@yahoo.com Thanks

I was denied by UHC back on April 8,2010. I took me until July 21st to submit my appeal letter because I had to make sure I put every single detail in the document. I submitted 26 pages of information and labeled them all as exhibits. Here is a copy of the letter I submitted. My denial was overturned on August 5,2010.

August 11, 2010

Dear Medical Appeals Division,

I am writing this letter to appeal the United Health Care decision to deny coverage for LAP BAND Surgery. Based on the letter of denial dated April 8, 2010, this procedure was denied because “no five year medical history." According to the Benefits Department at United Health Care there is no stipulation stating you must have five consecutive years of documented weight history but only five years which I have included with this letter.

As you may have based your denial on incorrect or incomplete information, I wanted to provide the following information that shows why I disagree with your denial and why I believe LAP BAND Surgery will significantly benefit my health and should be approved.

At this time, my doctor Pamela Thompson believes that LAP BAND Surgery is medically necessary and is the appropriate treatment for the below mentioned health conditions. I have also included with this document a letter from Dr. Jamal Farhan stating that I meet the requirements for the Lap Band Procedure.

8/20/02- IUD removal, weight 298 lbs- see attachment A

4/6/05- Diagnosed with Extreme Obesity, Fatigue, Back Pain, weight 316 lbs, medications noted Adipex and Merida- see attachment B

5/9/05-Diagnosed with Obesity, f/u for back pain and fatigue, weight 312 lbs-see attachment C

7/10/06- Diagnosed with Obesity, weight 313 lbs- see attachment D

1/19/07-Diagnosed with Morbid Obesity weight 326 lbs, fatigue and snoring, medications Adipex and Provera - see attachment E

2/21/07-Sleep Study- see attachment F

10/23/09- Diagnosed with Morbid Obesity weight 350 lbs, BMI 54- see attachment G

1/22/10-Diagnosed with Morbid Obesity weight 354 lbs, BMI 55-referred to specialist for lap band procedure-see attachment H

2/24/10- Went in for initial consultation with Dr. Jamal Farhan at Hurley Medical Center

I also have a family history of stroke, diabetes, high blood pressure in both my parents and heart attack.

Can someone help out on ideas on what to put on my appeal ?

I am frustrated, as my LAP-Band procedure was denied by Tri-west today!

I did the "scavanger hunt" (PCM referral for consultation and seminar, attended the seminar, met with my surgeon, met with the psychiatrist, etc.. everyone approved for me to get my lap band surgery - except TRIWEST).

I sort of know that you either are 200% over your ideal weight, or weigh over 100 lbs plus have 1 morbid disease.. (HBP, Diabetes, etc.) to be approved for the procedure.

I am 100+lbs overweight, and with no co-morbid diseases.. However, I had Gestational Diabetes back in 2009 and had my gallbladder removed back in 2005. Have a family history of HBP, Heart attack, diabetes (granparents), and my dad actually has type 2 Diabetes. I've had anxiety attacks in the past, but other than that.. .. that's it.

Any suggestions on what to submit on my appeal ??? Referrals?? etc.. ?? I'd really apprecciate it..! Am frustrated and heartbroken! :S 2 months of doing all this .. to get a no..

I have Tri-West too and Im just begining the process. I am scheduled for a seminar for April 23 but that is as far as I have gotten. Do you know if I need referrals from my PCM to see the surgeon?

I hope your apeal goes through. Good luck!

Thanks "Navywif99" ! Still working on it !

I dont think you need a referral for the seminar. But you'll definetly need one from your PCM for your 1st consultation with the surgeon otherwise the insurance wont pay for it. After that, you'll probably need to see the psychiatrist for a pre-op evaluation (you'll need a referral from your PCM too), and after the psychiatrist submits your evaluation to the surgeon, the surgeon will submit all the packet (PCMto Triwest and see if they'll approve your surgery. At least that's how it went with me.. it might be diff. .. dont know..

But good luck with the journey !! )

I have Tri-West too and Im just begining the process. I am scheduled for a seminar for April 23 but that is as far as I have gotten. Do you know if I need referrals from my PCM to see the surgeon?

I hope your apeal goes through. Good luck!

Thanks "Navywif99" ! I'll definetly need all of that ! )

About the referrals.. you'll definetly need it for your consultations, etc.. but not for the seminar. But make sure before you see the surgeon (at the consultation) you bring your referral from the PCM other wise.. Tricare wont pay for it.. It took me like 3-4 days to get it, without counting the days I had to wait to see the PCM ) hehehe

Good luck ! and hope all works out for you too!