Not denied, but more testing needed...so discouraged.

tomatogirl · October 3, 2008

OK, so here's my story:

My paperwork was submitted on Sept 8. They finally accepted the paperwork Sept 26th(ish) :lol: - they never could give me a straight answer to why accepting it had taken so long, but that is neither here nor there. Every. Single. Day. I have called to see if they had an answer yet and every day it was the same thing, "Any day now!" :w00t:

Well, today I woke up frustrated and I spoke to a represenative, who transferred me to a medical manager, who transferred me to the main office in Cali to speak with an outpatient manager, who transferred me to the crankiest woman who was the outpatient manager of the DC area :lol: , who gave me the number of the head nurse who reviews surgeries for the DC area. I spoke with her and she said that she had JUST gotten my case that morning and she would review and call me back. When she called me back, she told me that I needed more labs and a psych eval:sad:. She asked why I hadn't had them and when I told her that I went by the requirements that TRICARE gave my surgeon's office, she gave me some nonsense about how all the information isn't there for the reps to read to the people calling to ask- that that TriCare website only says that you need the weight/BMI/co-morbidities. It fails to mention the required tests, psych eval, and nutririonist visit. Luckily, I've already seen the nutritionist, so that's one less thing to do and I had asked my PCM for a psych referral ages ago when I started all this, so I don't have to wait for that, either. I called my PCM and she put in for me to get the labs I was missing (H. Pylori and TSH) and my surgeon's office is finding a psych who can give me a consult ASAP so that my husband doesn't have to try and change his leave. I'm just so upset. I thought I was so close to having this done and who knows when I'll be done now. She said if I just get this stuff done, she can approve my surgery. Honestly, though, if I weren't so close, I'd probably just give up.:thumbup:

audreym · October 3, 2008

Sorry to hear that they are putting you through such crap. I had my band put in 09-03-08 through Tricare South. Although Tricare covered my surgery (Thank goodness) I had to pay out-of-pocket for nutritionist/psych/physical therapist/and Preop meeting (about $775 total). Their reasoning - because Tricare doesn't require all of those things - those are individual physician requirements and they don't cover them. Tricare ONLY requires the "100 pounds/double ideal weight/ BMI 40 or more/BMI 35 or more with comorbities".

This was their story in August and now your office is telling you that they require more tests - Something is definitely wrong at your Tricare office!!! Additionally, most of us on here who used Tricare got our approval in 48 - 72 hours (check the other Tricare threads).

Sorry - I wish I could be of more help - Keep hammering at them and I wish you the best!

tomatogirl · October 4, 2008

Sorry to hear that they are putting you through such crap. I had my band put in 09-03-08 through Tricare South. Although Tricare covered my surgery (Thank goodness) I had to pay out-of-pocket for nutritionist/psych/physical therapist/and Preop meeting (about $775 total). Their reasoning - because Tricare doesn't require all of those things - those are individual physician requirements and they don't cover them. Tricare ONLY requires the "100 pounds/double ideal weight/ BMI 40 or more/BMI 35 or more with comorbities".
This was their story in August and now your office is telling you that they require more tests - Something is definitely wrong at your Tricare office!!! Additionally, most of us on here who used Tricare got our approval in 48 - 72 hours (check the other Tricare threads).

Sorry - I wish I could be of more help - Keep hammering at them and I wish you the best!

I know it's total BS. My doctor's office even told the nurse that it was rediculous to keep me waiting so long and then go, "Oh, BTW, you need to do ___, ____, and ____". In the month I was waiting, NO ONE could have mentioned this to me??!?!

mljalways · October 4, 2008

I was just denied the nutrionist appt and I too have to pay out of pocket for the physch eval, thankfully my total should only come to 300.00 dollars. I have found that there are extreme differences in the west and the south. The west is much more difficult!

tomatogirl · October 8, 2008

Well, I have my psych appt on Thursday (thank goodness I already had the referral in place for it) and then I'll be finished with everything and officially approved. thank goodness.