Denied-starting appeal process

i2candoit · June 8, 2005

I got my denial letter today from Triwest (which is Tricare technically).

It's the insurer for the military.

I'm starting the appeal roller coaster, but I have a few questions for you expert bandsters and am seeking some guidance.

Tricare Decision:

Our determination was based on the following: The Tricare Policy Manual Chapter 1, Section 2.1, indicates that regulations and program policies restrict benefits to those devices, treatments, or procedures for which the safety and efficacy have been proven to be comparable or superior to conventional therapies. Any device, medical treatment, or procedure whose safety and efficacy has not been established is unproven and is excluded from coverage. This exclusion includes all services directly related to the unproven device, medical treatmen, or procedure. This is a factual determination.

It sounds to me that they are saying its proven comparable to RNY or VGB so it is denied and/or it hasn't been proven so its denied. So they've got me both ways.

Can anyone disect this out and give me their opinion?

Also, In the appeal package I have:

1) Doctors re-submittal letter (She said she is going to change it around.

I also let her know that Inamed will help her with the appeal.)

2) Personal letter from me

3) Some documentation from obesityonline.com

4) Documentation about the Tricare VA (vertans affairs) policy pages

I got from the internet saying its covered for them. (how can one

government policy cover it and not another....we are all Federal

military (active or not)).

5) ?

6) ? any other ideas or research findings I may add?

I appreciate your help and love this website.

GeezerSue · June 8, 2005

I don't read that the way you do. To me, it says "We cannot and will not approve anything that is not as good as or better than conventional therapies"...and "conventional therapies" usually means RnY.

If that is the only basis on which they have denied the claim, then your job is to prove to them that it IS as good as or better than RnY. None of the other stuff--letters and documentation, etc.---matters.

So before you send all of that stuff off, call Don Mills at Inamed and ask him for the citations (in peer reviewed medical literature and such) which establish that the band IS as good as or better than the conventional therapies.

I don't mean to sound bossy on this point, but I think people get so wrapped up in trying to get the band, that they miss the details. The deal is that once they have denied you based on their excuse that the band isn't good enough, the ONLY argument that matters is that the band IS good enough...not how much you deserve it or messed up your life is now or how much better it will be after you lose weight, or that sort of thing.

In fact, when our daughter was denied for BR surgery, the letter included the cites for their side of the argument. I used other points made in THOSE SAME ARTICLES to argue our side and they could see that it was just going to be enormously difficult to win a debate with a mom who had nothing better to do than read medical journals, and she was approved. Just remember that you need to focus on providng them with data which disproves their data, and therefore undermines their argument...which also would include other plans which a) have a similar efficacy and safety clause, and approve the band.

Good luck.

Alexandra · June 8, 2005

I agree with Sue. The only thing Tricare needs to hear now is that the band IS as safe and effective as RNY. Don Mills can probably help you with this; I'm sure there are more recent studies available that can support your contention that the band is safer and as effective for RNY for you.

Good luck!!

i2candoit · June 8, 2005

Thank you, and I don't think you sound bossy at all.

My first instinct after reading my denial was to prove to them that the band is proven. Your insight, prove it is as good or better than other procedures, is great because as I kept reading it over and over trying not to miss anything I think I read more into it and started getting wishy washy. If that makes sense.

Now, wouldn't mentioning the fact that they cover the band for their VA patients part of the proof of it being proven effective?

I have spoken w/ Don Mills before and I just left him another message. He is an extremely nice man.

I was afraid not to put a personal touch on it. For some reason I thought that was important.

So bottom line--Just keep it straight forward.

GeezerSue · June 9, 2005

Alex is the expert on how to communicate with the insurance company. I was just trying to focus your efforts on how to "beat" their argument. (On another support site, I "insulted" someone because I felt her letter sounded to much like she was trying to prove she "deserved" the surgery...which wasn't anything her insurance cared about. Nor did they care about her low self-esteem, or any one of a number of other things that were mentioned. Insurance companies do not approve surgery we "deserve," they approve surgery we are "entitled to.")

i2candoit · June 12, 2005

Would one of you ladies be willing to read and comment on my appeal letter I am writing.

I can send it to you.

The insurance dept with the doctor is working with Inamed at this time for their part of the appeal.

i2candoit · June 13, 2005

its okay. I spent a few days doing research and sent it off the the docs today.

I don't need it read.

Alexandra · June 13, 2005

Good luck!! My fingers are crossed for you.

sandie1958 · June 13, 2005

i hope this isnt a bad sign!!!! my dr. office sent in my paper work to united health care 6 days later i got approval letter but it was for gastric bypass. so i called the dr . office insurance lady said i am so sorry i coeded it wrong. would you rather have the bypass? i said no mam so she resubmitted it . i called uhc today it is still in review , it had been in review for almost 10 days. why so quick for the gastric & not lap band my insurnace covers both. i have a tentative date for july 11-14,. they gave a 4 day window? what do yall think? sandie

Alexandra · June 14, 2005

Sandie, I think you're in good shape. Once you're approved for one kind of surgery, if the carrier doesn't exclude a different treatment for the same condition you'll very likely be approved for that one as well. And we know United doesn't exclude the band, so your approval should be quick.

It's a good idea to call again, there's no reason it should take so long. And yes, you should have it in plenty of time for a July surgery date. Let us know how it goes!!