Insurance says no, so now what

I helped one VSG-OH member write an appeal when her insurance denied her, but it was because she had not presented a significant amount of evidence as to why they should allow the surgery and pay. She re-presented and they paid. This sounds a bit different, more like a policy issue within the insurance and I don't know that an appeal would impact that. But I say go for it, and send it to the policy makers at the insurance co. as well as the appeals board. Ask your doctor to help give you tips on how this procedure is less invasive, has less risk and all of the benefits. Make a case, attempt to create change. Go or it! If that is too much for you then either wait it out, have the RNY or pay out of pocket. A lot of people on this site have seen doctor Alvarez, and have been quite successful. Good luck to you.

Drum has MTF but no hospital. I am retired Army, so I see Tricare network providers in the community not at the MTF. Going to ask questions of the HBA and see if I can transfer to Drum MTF and maybe get put on list at WRNMC. Just not sure if retirees priority would be high enough to get me in, but worth a try.

Sure wish they would explain how it is unproven. I know 5 RNY patients (personally). 3 are as large as they were before surgery, 1 never lost much to begin with. 2 lost and regained most if not all and 2 lost and are maintaining 5 plus years out. that in my mind is only a 40% success rate. And yes I know it is a tool and those 3 may have misused their tools, but all the research I did over the last year show longer term better results with VSG.

And it is true I know nobody that has VSG, except those on this site, so I would be the trailblazer around here. No one in the area support group that I have met has had VSG. Many have RNY and it seems to have worked for them, but maybe I am only seeing the successes come to the meetings.

I am in the wait it out and hope they change their mind mode right now. Kind of sucks a bit since I was scheduled for Feb 6th (if it was approved). I was in the home stretch and now stopped in my tracks.

Thanks for your comments, and any others are welcome.

No need to contact HBA really.  Go to your local Tricare office or online or call and request a PCP change.  Drum has right of first refusal.  So if Drum has capacity they will pick you up.  Then they can refer you to a MTF (refferal) to another MTF that does the surgery.  The Navy MTF here in Jacksonville make patients go through their programs.  

Drum pushed many beneficiaries into the community due to lack of resource. That was in the past. Currently they are starting to regain patients by assigning all new arrivals to Drum. Just have to try my hand at convincing them to let me in. Also everyone I know that is currently in the Bariatric Surgery process is assigned locally (Syracuse). Havent found any sent to Bethesda which is nearest (I think) Medical Center. Possibly West Point, but don't know of any there either. But at least now I have a trail to follow. 

Just dont want to jump out of one cart and into another unless I know the new one will get me to the goal. Been over a year working with this doc and getting all the prelims completed.

Whatever it takes

When you contact Tricare to change PCP, you can ask that if your choice is not available to just let you stay where you are.  They did that for me.  I was lucky enough to get the MTF here to accept us.  I still got a refferal to the civilian surgeon since I had already ompleted their program.  Send me a private message and I can tell you more on how I got the sleeve done.

 If you decide to go self pay, look into Mexico. Seriously is a very good option, for those who can't get it funded through insurance and can't afford local costs. inquire about the top surgeons, on the main board, and you will get tons of responses. Good luck.

So insurance company calls to tell me claim is going to be denied. They suggest (like I wasn't going to) I appeal their decision. She says while it may not overturn this specific decision, they tend to look at procedures that get a high rate of appeals to decide if they are going to modify their policy and cover them in the future. 

So if you are a Tricare Beneficiary and want the VSG instead of another type of Bariatric Surgery, then make them tell you "no" and then file the appeal. You can always change your mind if you want/need a surgery right away. But it will assist others in the future to have this type of procedure.  It was not to long ago that Lap Band was not covered by Tricare. She tells me this is how they got that procedure covered. It does take time, but I do have the luxury of time.

I am also pursuing the MTF option referenced in previous posts. Guess I had more fight in me than I thought.

Will do the Mexico research after I exhaust all other options, because I really don't have money to self-pay.

So bottom line, ask for VSG and appeal it to Tricare for all your future OH friends.

Thanks Again

In case anyone is still watching.
If Tricare says no, appeal the decision to clear the path for future VSGrs.
Then/same time
Go to your PCP and have them write a specific referral to the nearest Military Major Medical Center that performs the procedure. I am in the process of doing this now.
I am told that Tricare and your local MTF facilitate the referral being processed to the MMC and assist in getting your initial appointment there.
I will update as I gather more info.

I just saw this post and am in the same boat.  I'm terrified of RNY and have no interest in bands.  I have my heart set on the VSG procedure......and I have Tricare so obviously I'm at a crossroad.  Have you had any success with your appeals?