Plastics Denied...as expected

Well, I was trying to be positive and also not think about the "everyone gets denied" senario, and just give it over to Jesus, which I did, but everyone of the requests was denied...so the fight begins!!! I hate fighting, but I am not giving up and I am going to do whatever I need to do in order to get my plastics. I cannot afford the $20k having just moved, and everything is so expensive out here. Plus, we need to save money to buy a house next year, and I cannot justify it for plastics. I don't want to finance it becuase that would just be another bill, and so now all I can do is appeal it. If anyone has ever appealed Tricare Standard before for anything, please let me know so I know what I need to do. Thanks!! Hanging in there... Deb

What all were you trying to have done....or what was quoted for the $20K?

I got the denial letter in the mail today, and it said: "Our determination was based on the following: the TRICARE Policy Manual Chapter 4, Section 2.1, indicates that benefits are generally not available for cosmetic, reconstructive, and/or plastic surgery except under certain limited cir****tances. Based on the information submitted, this request does not meet policy criteria for TRICARE coverage." Anyway, I do meet the criteria for having had gastric bypass, so these fools will get the appeal letter from me. So, Just wanted to update you guys on the whole Tricare thing as I know some of you are Tricare. Love, Deb

This is the same section of policy I emailed you. I think you will also have to make the argument of how having this surgery will repair some bodily function to 'normal'........in other words how does your excess skin interfere with your normal life. Just having the GB will not necessarily qualify you unless you can also win them over in this area as well. Good luck!

NO WHIMPING OUT NOW, MS DEB ... YOU GET IN THERE & FIGHT FOR YOURSELF! BUG THEM TO DEATH UNTIL THEY APPROVE YOU JUST TO GET YOU TO LEAVE THEM ALONE. OK, FIND OUT E-X-A-C-T-L-Y ON WHAT GROUNDS THEY DENIED YOU & GO FROM THERE. GET A COPY OF THE MEDICAL RECORDS & DOCTOR'S NOTES THAT DR KATZEN SUBMITTED WITH YOUR ORIGINAL REQUEST SO YOU HAVE A BASIS OF WHAT & HOW TO FIGHT THEIR DENIAL. MAYBE HE DIDN'T EXPLAIN YOUR ISSUES IN GREAT DETAIL ... MAYBE THERE ARE ISSUES YOU DIDN'T TELL HIM ... MAYBE THERE ARE ISSUES YOU ONLY DISCUSSED WITH DR BYRNE THAT SHOULD BE USED FOR THIS CASE. REMEMBER WHEN WE WERE TRYING TO GET OUR GASTRIC BYPASS, I SUGGESTED THAT PATIENTS WRITE THERE OWN LETTERS EXPLAINING 2 THINGS ... YOUR MEDICAL ISSUES & HOW YOUR LIFESTYLE IS EFFECTED BY YOUR CONDITION. WELL, DO THE SAME HERE ... DO YOU HAVE RASHES? DO YOU HAVE A HERNIA? DO YOU HAVE LOWER BACK PAIN? DOES THE TUMMY SKIN FLAP CAUSE PROBLEMS - WHAT KIND? DOES THE UNDERSKIN OF THE TUMMY FLAP STAY MOIST, HAVE AN ODOR, ITCH? ... GET INTO DETAIL AS TO WHY THIS IS MEDICALLY NECESSARY & BE SURE TO STRUCTURE YOUR LETTERS BASED ON THE CRITERIA TRI CARE ALLOWS FOR THIS SURGERY. TELL THEM HOW MUCH YOU'VE LOST WITH THE GB SURGERY & HOW YOUR LIFE & HEALTH HAS IMPROVED, BUT, BUT, BUT HOW THE TREMENDOUS WEIGHT LOSS HAS LEFT YOUR BODY DEFORMED WITH MEDICAL & PERSONAL ISSUES. TALK TO THEM LIKE YOU ARE TALKING TO YOUR BEST FRIEND. IF YOU ARE EMBARRASSED DURING SEX, DETAIL THAT ... WHATEVER YOU EXPERIENCE NEGATIVELY DUE TO THE EXCESS SKIN. MAKE YOURSELF TAKE UP-CLOSE & PERSONAL PICTURES THAT SHOW THAT THIS IS NOT "JUST COSMETIC". REMEMBER, YOUR REQUEST IS GOING TO HUMAN BEINGS WITH ISSUES & EMOTIONS & PROBLEMS IN THEIR OWN LIVES SO THE MORE PERSONAL YOU BECOME TO THEM, THE BETTER CHANCE YOU HAVE TO GET APPROVED. TELL THE TRUTH, BUT BE SURE TO USE THE TRUTH TO YOUR GREATEST BENEFIT. GOD BLESS YOU ... DAWN & NICK

I am going to fight it, I am not whimping out. I think I have to just try to get one procedure approved at one time, that is the key. My doc tried to throw everything in there at one time, and that just hurt my chances of getting anything approved....they were like, "who is this lady thinking we are going to do a makeover on her"? So, I am going to go and get new documentation and re-submit it. Britty got approved for one procedure, so now that is my goal, one at a time. Thanks for the support!!! Even though I knew it was going to get denied, I still felt terrible and hurt, and bummed Its okay, I will fight and get it done one way or another. Love, Deb

Good for you, sweetie!!!! Chin up! I know the plastic surgeons like to do several surgeries in the same area of the body at once ... Breasts & arms ... Tummy, & vaginal area ... Legs & butt ... But, you may be right, Tri Care may think you're asking for too much at once. Did you see the post from Ms Kimberly (I think it was Kimberly) where she said that you need to convince them that there is a medical or lifestyle problem that the surgery will correct? ... That was what I was trying to say in my round about way when I was talking about you writing a letter about your issues & how they could be corrected just like many of us did when we were trying to get GB surgery. She said it a lot better than I did. Keep us updated ... I have no doubt that you will be approved!!! God bless you ... Dawn & Nick