Tricare

[high1988]

I have recently been disapproved for ADR through Tricare. I was injured while on Active duty. They gave me the option of getting a fusion but I refused due to mobility, recovery time, longevity and the better chance of return to full duty. Does anyone have any suggestion on dealing with appeals for Tricare. Appeals for any insurance company?
Thanks in advance

[mosullivan86]

Hey High,

I just got surgery approved through Tricare standard (husband is active duty). They approved it first try. Where are you located? DR B's office said I was the first patient that had ADR approved through Tricare for them without a fight, everyone Was very surprised.

[donmas2000]

Hi high1988, as i thought fusion is gold standard and L5S1 has no much movement on it. L5S1 manly deal with compression on the spine so think fusion on this level will still be ok. As i also has problem on this level and still thinking fusion or ADR on this level. I just afraid about the facets joint problem in the later stage and a revision on it with risk on life. As i meet a guy also choose fusion on L5S1 as he dont want to risk on another operation on the same level. Please let me know what your truth thought on it. As i also know fusion may take more than 6 month to fuse or a year to fully fuse. Cheers

[high1988]

mosullivan86,
My apologizes for the late reply (new to the cite). I am in Augusta GA. I am surprise they didn't give you the run around too. Awesome job. What did you do to get approved?

[high1988]

donmas2000,
I did a lot of research on the difference in the two. While the fusion may be good for some, I prefer the ADR. Several reasons I prefer the ADR for the following reasons "but not limited to":
1- The return to duty is much quicker
2- Average recovery time is quicker
3- It's approved by the FDA
4- It preserve mobility
In addition, I am a marathon runner, I need all the mobility that I can get.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176705

[mosullivan86]

High,

Unsure, I have been dealing with my neck issue for around 3 years. I've done a few rounds of PT, no injections (not interested in that, and Drs say I wouldn't get any relief due to the compression on the spinal cord). Do you know which insurance group covers your region? (Humana, united, etc?) I know Humana has different rules of what they approve than united does. United is who approved my surgery.

I would also recommend calling a tricare liaison or patient advocate at your base. They helped me when I was through standard and just starting with this whole mess.

[high1988]

mosullivan86,
We are in the Humana (Tricare South region). It's a shame that different regions have different rules. A Soldier is a Soldier is a Soldier regardless of where they live. I'm in the process of dealing with the patient advocate now. I have submitted all the paperwork and I am waiting on answers. This will be my last stop before contacting my congressman. I don't think they would like that.