Question:
Denied again....now on 3rd appeal
Tricare came back on the initial request for surgery and stated that it looked like I had a snoring disorder, not apnea. I appealed and showed further sleep tests and another doctor's note from my neurologist which clearly stated apnea. Now, Tricare doesn't state to what degree of severity the apnea has to be, just that apnea is considered a comorbidity. They now came back and said that I do have apnea, but not severe enough and that I am only 12# away from having a 35 bmi, so they denied me again. I went and had myself remeasured I am 5'7 1/4, not 5'8, so this ups my bmi even more. I don't know what happens if the 2nd appeal is denied. Do you all think it is too late to contact the appeal agency and tell them I was measured wrong? I am about ready to eat for the next week and gain the 10 or so pounds needed to put me at a bmi of 40...this is crazy. Used to be that you had to be at least 100# overweight to get the military to help you, now that isn't enough. Maybe had they had a weightloss program around when I was 15 or 16 when I was only 10-20 pounds overweight, they wouldn't have to be dealing with me now... Sorry for the rant..just frustrated. Colleen — Colleen R. (posted on June 24, 2002)
June 24, 2002
So Tricare is insurance for military? I've been out of the military loop
for 20 years. We had CHAMPUS for use when we weren't on base back then.
Sooooo......if Tricare is health insurance for military, I have an
idea.......how about contacting your congressman and senator (from your
home town, not your base) and setting forth your frustrations with them?
Also type up a letter to the insurance company saying absolutely everything
over again, outlining why it's not fair, how the weight affects you and
basically rant and rave. When you're done with the first draft of both
letters, take a breath and then revise each letter so they aren't
accusatory or mean and send them out. You can probably even fax them for
quicker response. Right now, esp., congressmen are out to help the
military! Let me know if you need help finding your congressman, etc.
— Nell C.
June 24, 2002
Colleen...I am also on Tricare. Do you have PRIME? I know from my surgeon
that it can make a difference. Also, where are you? It could be different
depending where you are, but here at Ft. Bragg (we now actually have a
Bariatric Surgery Center in Womack Army Hospital!!!), you MUST have a BMI
of 40 or more; however, a BMI of 35 is acceptable with medical proof of
certain comorbidities. My only comorbs were joint degeneration and
incontinence, so when my doc found my BMI to be JUST OVER 40, he urged me
not to lose any weight, but Tricare had not trouble approving it. Feel
free to email me about it. I am going to be away from Wednesday the 26th
until at least that Saturday, but I will help you in any way that I can.
Good luck!
— Suzanne S.
June 25, 2002
I know how you feel, I have been on a emotional rollercoaster every since
last year. Let me tell you my story, I had been waiting just to see a Dr.
(had to have a referal), since last April. I just knew when the Dr. saw me
that he would say yes, the surgery is medically neccessary. And he did my
BMI was only 39. Both sides of my family has history of High Blood pressure
(which mine is borderline),stroke, diabetes, heart condition you name it
they have it. My husband is Active duty so therefore we have Tricare Prime.
SO the Dr.'s office sent the paperwork for approval up, I just knew I would
be approved, since three ladies I worked with had no problems being
approved, there BMI is higher than mine but they had the same insurance.
Nevertheless. DENIED. the first time. I got upset and sent a second letter,
the Dr.'s office didn't really fight for me they did write a sorry letter
about nothing really good, they had me at a large frame I am 5'2, and
220lbs, I should have been a small frame and that put me at 100lbs
overweight. SO I wrote Tricare back and they acknowledged I was 100lbs
overweight but what about my comorbities, I told them about my ankles bad
knees and back, but they wanted it to say Arthritis, so i had my Dr. write
Arthritis. DENIED again. They wanted documintation of Arthritis. I was so
depressed, because I couldn't understand Tricare, why would they want me to
risk myself to become worse off than I am. To charge them more money
because all I would do is keep going back to the hospital to ask for more
Motrin, Naproxen, tylenol to help the pain go away in my knees and back. So
to make a long story short I asked my PCP if he could refer me to a
military Dr, hospital, and he has given me a referal. I do not know the
verdict of this, but I hope and pray everything will be fine, I had all my
blood work done and psych report done and she said it will help me to have
the surgery. I don't even care if I have to pay for a plane ticket out of
my pocket. I do have faith and I know that is what brought me this far. If
any questions email @[email protected]. Good luck
— Tina B.
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