Question:
TRIWEST DENIED CLAIM AFTER TRICARE HAD ALREADY APPROVED NEED HELP

I had my surgery 9 mo. ago under Tricare Prime (military) My friend who is 105 lbs with 40.1 BMI was originally approved by Tricare in May 2004 for her surgery in July 2004.. Needless to say Triwest took over in June 2004 and suddenly denied the surgery... I am trying to help her write an appeal and would like to get a list of people who have either been approved under TRIWEST who have the same demographics or are going thru the same thing. OR ANY INFO THAT CAN HELP ME WITH HER APPEAL PLEASE HELP. Thanks Angie    — Angie-H (posted on August 19, 2004)

August 18, 2004
Possibly it was denied because the approval was for Laparoscopic? Since January 2004 Tricare has been denying Laparoscopic Gastric Bypass. Tricare clients now have to have the invasive more expensive Open Gastric Bypass. My daughter tried to appeal twice and was denied both times. It really doesnt have anything to do with with the change. They are saying that Laparoscopic Gastric Bypass is unproven and experimental.
   — jenafwife

August 18, 2004
Your friend should contact her Tricare office immediately. I don't know where your friend is from, but Healthnet was originally in charge here in CA before Triwest took over. Triwest was to acknowledge and keep all prior approvals with healthnet. Your friend should bring the original approval number (tracking number) from May 2004. If it was approved, Triwest will acknowledge it. I haven't heard anything about the lap procedure not being approved. There are tricare prime folks here having it done lap to this day. (that's the way I had mine done) Have your friend contact the local tricare office. There should be one locally if a military installation is close by. They can help sort through everything.
   — dimpkd

August 19, 2004
http://www.tricare.osd.mil/faqs/question.aspx?ID=1218
   — jenafwife

August 20, 2004
I know that Tricare (TRIWEST) is no longer paying for LAP BPD as of January, 2004 because that is the first surgery that I applied for. After being denied, my doctor submitted a request for LAP RNY and it was approved within 48 hours. My suggestion is to call TRIWEST and talk to a representative.
   — AllisonF

December 2, 2004
Hello, My drama of the whole tricare/triwest is about the same as your friends. As of Oct 1 triwest will not pay for laporscopic procedure. I have done the whole appeal process and was denied the laparoscopic procedure because they say it is not an approved method and they don't even have a code for it. In the process of all this I was told by a rep a triwest that we had the right to appeal but it would be turned down because it is a exclusion and they hardly ever turn over a desion for a excluded procedure. I am going to have it done open but it has still been a nightmare trying to get all the authorazations I need
   — Shanon P.

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