Tricare question!

[Felisha 0]

Has anyone been approved with BMI/weight alone?

I have SEVER back and hip pain and am only 20 years old. I'm hoping to get surgery but now I'm starting to get very very worried.

They said I need BOTH weight of the 100lbs over and a whole long list of things. And I haven't had my physical yet but I don't think I have any of the other requirements.

So, Has anyone been approved w/ BMI/weight alone and how long did it take?

[Rsilversea 2]

It's been almost 2 weeks and I'm still waiting. My BMI is 40 and I'm in the ballpark for Tricare's policy but they are haggling over something. No clue what and my doctor's office is frustrated with them. So am I. I may have to adjust my surgery date because the doctor's office can't get in touch with the case manager and they needed an answer by noon today. It's past noon and I have not heard anything.

[Felisha 0]

My BMI is 44 and I'm .5lbs over the lowest number for lapband surgery in the 200% mark but my surgeon said I need to gain 13lbs.. idk why

[Rsilversea 2]

Well, I was just informed that I was denied. My doctor is going to call Tricare and give them hell, lol. Apparently they are rewriting the policy but it won't go into effect anytime soon. I may have to go through an appeal process but I hope to find out something more definitive from the doctor by the end of Thursday.

[Felisha 0]

Appeal appeal appeal!

[Rsilversea 2]

Until Tricare updates their standards, you will never get approved on BMI alone. I don't suggest gaining the weight just to get the surgery because I believe it will harm you in the long run.

[lucybugsmama 0]

I'm in the same boat. I went for my consult with the lap-band surgeon today and they said I'm in the range and are submitting to Tricare. I'm really worried that I won't be approved because the only comorb I have is reflux and that's not listed as a qualifier with Tricare.

I had bloodwork done a week ago and haven't heard back from that. It sounds relly messed up, but I'm hoping for high cholesterol or thyroid problems to up my chances of approval.

[Rsilversea 2]

I'm working on my appeal letter today. They have 30 days to respond but my doctor's office said they normally respond in five (I'm guessing that's "normal" insurance companies not Tricare). Hopefully I'll know by the end of next week or beginning of the week after.

[Rsilversea 2]

Doctor's appeal letter is going in today.

[lauragshsu 6]

I have tricare and had a BMI of 44, and got approved within 5 days of it being submitted. If you have any type of family history of any weight-related health problems, flaunt it to them. My dad was just diagnosed with diabetes and has high blood pressure and cholesterol. I made sure all that was included in the report the Dr sent to insurance.

[Felisha 0]

My mom has weight related sleep apnia.. would that work? And I think she has HIGH blood pressue.

[lauragshsu 6]

My mom has weight related sleep apnia.. would that work? And I think she has HIGH blood pressue.

I would definitely have the Dr include it. ANY type of ammo that can be used to win should be included.

[FattyCakes 0]

I called TriWest today b/c my friend told me that they'd approve me on BMI alone. The lady read out-loud just what I read on their web-site (with no mention of BMI) and I mentioned BMI and she said, yes you can get approved on BMI too. I asked her how she knew that and she said she's been trained on it. I told her I was scared that if I called back that someone else would say no..... So, it's not written in their policy that I know of, she's "just been trained." :thumbdown:

Edited May 4, 2010 by FattyCakes

[rucsac1971 0]

Well, I go for my consult today. Went and saw PCM on the 16th of April for the referral. Got that instantly almost now the hard part begins. I have the lab work results from that appt to take with me. It states that I have high chlosterol but barely but doctor also noted that the lapband surgery would correct the high chlosterol. Also taking with me results from sleep Study done several months back. I did not need the CPAP but doctors recommendation was weight management. Hope this is enough. Thought??? Tricare South Prime

[Rsilversea 2]

BMI is NOT in their policy although the policy is currently being rewritten. It may take 6 months to a year for the change to take place though.