I was denied by Tricare Prime west region (triwest) for gastric bypass. I am OVER 100 lbs overweight and a bmi of 42 with NO comorbidities.

I plan on appealing but what can be my fighting arguement since i have no documented health problems, no diabetes no hbp etc.. ?

I do not want to give up, do i have to finally get to the point of becoming diabetic for them to approve me?

Iam disappointed, but if anyone can give me any pointers or tips about how to make my appeal It will GREATLY be appreciated.

Also, does triwest automatically go by the medium body frame on the metlife chart? Or can my surgeon simply state iam small framed, if so i meet the 200% over requirement...(small framed)

Determined- I'm in El Paso/Ft Bliss too! I just went to the PCM today and they sent in my referral. I'm 240 lbs (which puts me at 100lbs overweight for the low end range for my body type) My BMI is 39, I have high cholesterol, high BP, and severe joint pain. What do you all think about my chances??

Determined- please keep me updated on your journey, and any advice/things to do would be great!!

Thanks!

Rubytuesday-- I personally think you have good chances of getting approved. As long as you meet their requirements which is 100 pounds overweight with one of their comorbidities (high bp)you shouldnt have a problem. Just make sure it is all documented and its all sent in, that way you wont have to appeal which can take up to 90 days, thankfully my appeal only took 30 days to be approved.

Also, have you registered online at triwest? I did that right after my pcm sent in my first referall for the surgeon consult and it was approved within 2 days.

Goodluck!! Feel free to contact me anytime if you have questions!

do you think you could help me out? i just found out today that i was denied! i have no clue why. i meet everything needed for tricare to approve me!!!! when i called them they said it could be because they do not have enuff info! BLA BLA! anyway i called my doctor and the surgeon who will do the lapband to help me appeal this. my quistion for you is.. did you have to wait the whole 90 days to hear something? and do you mind if i look at your letters that you wrote. may help me out. thanks so much. i really want to fight this so anything will help! thanks

karen

No problem, just PM me your email address and I'll shoot them right out to you.

DeterminedWifey- Thanks so much for the info. Apparently the referral has to go through the chief of surgery before being sent to tricare?? Also, I found out that Tricare Prime is referring people off post now. Have you been assigned to a surgeon yet? I'm so happy they approved you, and good luck!

My referral was also sent through the chief of surgery first but it really didnt take long to get the approval. I did have to follow up because my pcm "forgot" to send in the request.

And yes they are referring people off post (thankfully lol) They assigned me to a surgeon but i had already done my research prior so i changed it to dr.applebaum.

This coming week will be busy, they've scheduled me for psych eval on monday, nutrition on wednesday and surgery consult on thursday!!

Also are you getting the lapband? I decided on the gastric bypass, even though this is a lapband forum i recieved more helpful info on here than any other site!

Let me know how it goes!!

Gosh, good luck! That does sound busy. But thank goodness they're getting you in quick. The surgeon's office that I spoke to where Tricare Prime is referring people said they do everything in house. So that'll save time on appointments. I'm just dying to get my referral and get this thing started!

I am going for the lapband, mostly because I have a couple family members that went with gastric bypass, and didn't have the best time with it. Plus, I have a 17 month old daughter who demands mama be available, so I don't have too much recovery time open. How come you decided on the gastric bypass? If you don't mind me asking! Again, good luck!

well i decided on the bypass because i liked the idea of a "permanent" tool to help with the weight loss, and the fact i wouldnt be comfortable with something foreign in my body and im not going to lie, the drastic weight loss is appealing as well.

So what kind of problems did your family members encounter with the gastric bypass if you dont mind me asking?

you know, i don't know the exact details, but they both had leaks that were eventually fixed, but I remember it being a pretty big deal. and they both gained back all their weight, but i think that's a risk you always run if you aren't ready for the life style change.

keep me updated!

My mom had gastric bypass and she's been a mess ever since. Her intestines now have adhesions in them (since they cut and reroute your intestines) and stuff gets stuck in them. She usually ends up in the hospital with it about once ever 6 months. The rest of the time she deals with it on her own.

Because of that, every day of her life she's either throwing up or diarrhea. Her quality of life is now what it should be.

I know a couple other people who've had it and each of them have gained their weight back.

For me, having my stomach cut and my intestines removed seemed way more invasive than a "forien object" in my body. My sister commented on that too, but no one ever questions when someone needs a pacemaker, or if you break your leg and need pins to put it back together, or many other situations where there is a forien object in our bodies.

Anyway, that's just me. They both have their pluses and minuses, you just have to figure out what will work best for you.

Best of luck to you!

Edited August 24, 200916 yr by SuzanneG