Tricare Denied Abdominoplasty

I got my denial notice within a week of havinging my appointment with the Plastic Surgeon.  I though that was kind of fast.  I do plan on appealing, but does anyone have any suggestions or pointers to up my chances of getting an approval?  My surgeon sent pictures and all kinds of stuff.  Tricare did pay for my Gastric Bypass Surgery with no questions asked and I just slid in under the requirements.  Any help would be great!!!!

Jami
My experience has led me to beleive that when plastic surgeons submit paperwork they tend to reject it merely becasue it came from a plastic surgeon, My hubby tried going threw a plastic surgeon for a tummy tuck and he was denied and Dr katzen did not even try very hard and that was that, I went threw my doc who also did my lap band and I submitted documentation etc, In fact I got all my ducks in row the requirements and they could not deny it based on criteria was met. My hubby had hmo for his RNY and after 6 appeals it was granted after 3 years, The medical group decison was over tuned by health net in the end hubby had 12 co morbities. We finally switched to aetna PPO and I was approved w/ in a week for my lap band as well as TT. My 22 year old son was approved  for Lap band  after completion of requirements for Wls. Sometimes it is worth changing insurence to  get was is desperiately needed. I am so blessed to have a amazing insurence, I love aetna PPO they r the best.. and so worth the extra dollars we pay out of pocket we will never go back to HMO. They are truely not intrested in saving your life they are only intresting in giving u low standard of care u get what u pay for I truely believe. Good luck and keep trying
Lisa

First off what was the stated reason for the denial?  You want to refute that specifically.  Did your plastic surgeon submit documentation of your skin issues from your PCP.  I assume you have been seeing your PCP for skin issues.  You want documentation that this is an on-going problem that has not been helped by more conventional treatment.  The trouble is that Tricare knows that the plastic surgeon has probably only seen you once, maybe twice -- and that is not enough to document medical necessity.

You need to write a kick-ass letter telling Tricare how the skin effects your health.  They are not interested in how the skin makes you feel as psychological issues do not constitute medical necessity.



Red

I submitted over 50 photos of rashes and sores(took pictures of every pinhead size mark) along with statements from my Plastic Surgeon, Gastric Bypass Surgeon and Primary Care Doctor.  It took almost 6 weeks to hear from BlueCross but they approved it, after first saying they lost the photos so we needed to resubmit them.  They paid for my tummy tuck and arm lift.

Very hard to give any advice since you didn't state what medical reason your surgeon stated that you needed it. Also, many insurance co's require you to be 18 months post-op and that you can document that you have been at a stable weight for a certain number of months before they will approve someone who has had WLS. Your surgery was in aug 08 so you are only 8 months post-op... IF I were you i'd check my insurance requirements to see if they require stable weight/certain number of months post-op before proceeding further.

Also, if you could post more details here of what your surgeon said/your medical reason as well as the stated reasons for denial, you will get better replies...otherwise we have little info to go on and can only stab in the dark...

they probably denied you so fast because you are 8 months post RNY. Most ins. companies require 12 months post RNY & 6 months maintaining steady weigt you are only 8 months out evn though your weight loss has probably slowed down you are not finished losing weight.
before you start an appeal find out why they denied you because you may only be allowed to appeal this 1 x
Good Luck
Susan

 I have TRICARE Prime, and mine was approved the first time. It may be the code they used in the submission. Not sure what my PS submitted, but I believe it should be a panniculectomy. My PS did the abdominoplasty as part of the pannni procedure.  I was 18 months out and my weight had stabilized also.

Good luck!! I love TRICARE...have never had them refuse any surgery I have needed.

Tricare is getting a bit strange about everything...I don't know what is up.  We've never had a bit of trouble, up until last year...and they denied my MAMMOGRAM of all things!  I've been arguing with PGBA for over a year about that one!  We just changed status to Tricare Prime Retired and I'm scared to death about every little thing,  I'd always heard how wonderful they were about post WLS skin removal, tummy tucks, breast lifts, etc....but now I figure I've got no chance of approval!

Hang in there and stay after them...write down the date, time, and name of every single person that you talk to.  Back up every phone call with a letter to PGBA...then at least you'll have a mountain of meticulous evidence when your appeal goes before the medical review board.

Best of luck to you!!!

I believe it was submitted as an abdominoplasty.  I don't have the denial in front of me.  They stated that it was not a covered service.  I guess all I can do is appeal and have them possibly resubmit as a panniculectomy have a surgery date listed 1 year post gastric bypass.