Barbara - If you have the surgeon's office in their request for authorization for Lap band state that you are a small frame (documented by them along with your height & weight) you would meet Tricare's 200% requirement (see below) for 5'4" at 250lbs. You take 116 lbs X 2 (for 200%) = 232 or more pounds..... This is the route I took & it worked & got approved via appeal letter. The surgeon initially told Tricare I was a medium frame. After going back to my primary care MD & finding out I was a small frame, I then wrote the appeal letter with supporting note from primary care MD....
Here's Tricare's Policy (found in the TPM section entitled Surgery for Morbid Obesity, CH 4 Section 13.2):
Description:
Morbid Obesity means the body weight is 100 pounds over ideal weight for heith & bone structure, according to the mose current metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200 percent or more of ideal weight and bone structure.
POLICY:
A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one or the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height & bone structure & has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints. (NOTICE NO HIGH CHOLESTEROL IS NOT IN THIS LIST)
2. The patient is 200 percent or more of the ideal weight for height & bone structure. An associated medical condition is NOT required for this category.