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Tricare Approval or Denial??



Did you get approved by Tricare?  

7 members have voted

  1. 1. Did you get approved by Tricare?

    • Yes, I got approved. No problems.
    • Yes, I got approved and I was borderline the weight requirement
    • Yes, I was approved, only after I appealed.
    • No, I was flat DENIED.
    • No, I was denied and I did not try to appeal.
    • No I was denied, even after appeal.
    • I am waiting on approval.


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So.. after reading everyone's posts I am still a little confused.. I am currently 300 lbs at 5'8". Now these numbers qualify me for both small and medium frame for the 200% rule, but the issue is that my wrist measures 8" around which makes me large framed. To be at the 200% for the maximum of the large frame I would have to gain 27 lbs. I also dont have any comorbidites... I have slight PCOS and only a raised triglycerides. Everything else is normal!! (HOW IS THAT?!?)

My questions are...

For the 200% rule do you go by the max or the min for the range? (because if this is the case I am at 200% for the large frame which is from 146-167)

How much of a stickler are they with the whole frame thing?

Any info or advise would be great!! Thanks.

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Breanna, Sounds like you would be approved for the band. Just make sure you have all the required tests done. I thought I had them all done because I was going to have the gastric bypass on base and changed my mind because it is to drastic. They do not do the lapband so had to be referred to another surgeon. He required two additional tests, ( Upper GI and Cardiolite scan). I had them both done last week. I have my next appt. with the surgeon next Friday and hope to get a date. They still need to send everything into Tricare for APPROVAL. So it has been a long process for me starting with getting a referral for barairtic surgery from my doctor.

How far are you into the process. Maggie:shades_smile:

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Breanna, I don't think you will have any problems. I am 5'7.5'' and the weight they sent in to Tricare was 243. I did have a co-morbidity though. But to answer your question, no one ever measured my wrists or seemed to show any concern about my frame size whatsoever.

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Breanna,

Like Gina said...no one measured my wrists either to determine my body frame. I think tricare just goes with medium unless the doctor says otherwise. Also for my comorbids were self-referred. I told my lapband dr. that I have joint pain (plus my referral to the dr from the primary was for joint pain). I hadn't been taking any medication for it for a long length of time. I was 220 and 5'4 (approved in 3 days). So what do you have to lose...but weight!!

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No one measured my wrists. The number that Tricare gave me on my initial denial letter was the medium frame, lower number.

According to my surgeon's office, I needed to have all of the tests complete that tricare required. According to them, it was a referral from your primary,an EGD, EKG, Labs, Gallbladder scan (although I believe this was just my surgeon's request), and a Psy eval. You can self refer for the Psy exam, so find a Tricare Psy to give you an ok. You should have a sleep study done.

Good Luck!!

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Breanna,

Like Gina said...no one measured my wrists either to determine my body frame. I think tricare just goes with medium unless the doctor says otherwise. Also for my comorbids were self-referred. I told my lapband dr. that I have joint pain (plus my referral to the dr from the primary was for joint pain). I hadn't been taking any medication for it for a long length of time. I was 220 and 5'4 (approved in 3 days). So what do you have to lose...but weight!!

How are you? Did you have your surgery?

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My paperwork has been faxed to Tricare, so just waiting to hear the verdict. Approval, approval, approval...............

Karina, have you heard anything on your appeal yet?

The waiting is no fun. Maggie:thumbup::crying::thumbup::wink2:

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My paperwork has been faxed to Tricare, so just waiting to hear the verdict. Approval, approval, approval...............

Karina, have you heard anything on your appeal yet?

The waiting is no fun. Maggie:thumbup::biggrin::thumbup::thumbup:

Meggie, I hope you get it. We are in the same boat now. I'm waiting on my appeal but it can take as long as 60 days, and I guess they will use all of it and in the end will be a big NO!!!

I'm sure you will get it, keep ups posted.My fingers are crossed for you.

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Wow, 60 days for the appeal. Is that how long the original request takes? I just checked it on line and it has the letters np. What does that mean? I'm sure your approval will be approved since you meet their criteria now. Just keeping my fingers crossed. Will be gone until Saturday nite or Sunday. I have my surgeon appt. tomorrow morning, then I will be just staying down there thru most of the weekend. Good Luck, Maggie:thumbup:

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Wow, 60 days for the appeal. Is that how long the original request takes? I just checked it on line and it has the letters np. What does that mean? I'm sure your approval will be approved since you meet their criteria now. Just keeping my fingers crossed. Will be gone until Saturday nite or Sunday. I have my surgeon appt. tomorrow morning, then I will be just staying down there thru most of the weekend. Good Luck, Maggie:thumbup:

Is NP Non Provider???? Mine it is also a non provider, but they told me this is not a problem. We have no MTF here.I think you will be approved. JWRN was approved on her appeal in 4 days, but they do tell you UP TO 60DAYS so there is nothing I can do about it. The approval should not take more then 5 days unless they have questions to the Doctor and they take long time to get back t Tricare(happened to me). Let us know as soon as you find out. Oh I just found out th eweb site is 24hous behind, so try callling tomorrow to find out.Or even today.I would.

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Karina, I'm using my son's computer to check in. I saw the surgeon today and they have scheduled my surgery for October 1, pending insurance approval. Wow, that is less than 2 weeks. He only requires 24 hour fast before surgery. I checked the Tricare site and it hasn't changed. Will it actually say approved on it? I am going to check it again tomorrow. I would have called, but it is to late now. Does Tricare pay for fills? Here's to approval for both of us. Maggie:thumbup:

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I just received my Tricare approval on September 17th. I was first denied because I didn't weigh enough and no co-morbids. After two plus months of medical records, weight gaining, etc., I am now qualified on my weight and have been able to show two co-morbids (Sleep apena and arthritis in knees). Plus I am pre-diabetic, have a heart valve issue, and hypothyroidism. I don't have my surgery date yet, I am hoping to find out today.

Good luck to everyone and thank you for your support and a special thanks to Suzanne for her appeal letters.

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Maggie,

Find out why you were denied, and then meet those requirements. I talked to some people at my support group tonight and it looks like it is not uncommon for Tricare to deny the first time and then approve.

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Tricare is dragging their feet on me after my PCM dragged her feet. I'm getting really frustrated.Hopefully I will know this week, although at this rate I'll be a Notorious November. :smile:

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