I was told last year I was approved for surgery via Tricare & today not sure?

[mmbell 0]

I am very frustrated today. I went in for my consult at Weight Loss Surgical Center in KC last November in which they checked to see if my insurance would pay and I received a phone call saying they would pay but it had to be done at an acute care facility which they did not have but were in the process of building one. Fast forward to a month ago and I called to check on the facility and if it was completed & they had just done their 2nd surgery there so the ball starts rolling again....get phone call to set up another consult OR pre-op visit. I was on the fence whether to do it or not and after joining this group and reading the success stories I am 110% committed so left 2 messages to set up pre-op consult and the person that gets insurance clearance had been calling me WEEKLY to update me on Tricare's requirements that were being met each week SO I think as soon as the facility meets Tricare's requirement I am a go....NOPE....now I'm told that my BMI is under 40 and I do not have the 2 co-morbidities to qualify. WHAT!?!?! Talk about popping someone's bubble fast that was ready to get this going..........so now I wait as they try to gain clearance from Tricare. Why would they tell me last year that they would defniitely pay for it and now possibly NOT? They had the same requirements last year that they do today. Very disappointed & upset.

Anyone else have to deal with Tricare? Do they pay for your fills as well? I have a $1,000.00 family deductible which I met last year from being in the hospital twice and if I could have had this done before Oct 1st I would not have had to pay a dime! But my health is worth the $1000.00 at least and I just want to do this and I think if I'm denied I will really fall in to a deeper depression...I don't want to have to eat until my BMI is over 40 to get the surgery so I may be left of my own. I lost 84# once before but its all back and then some. They think my thyroid issues will count so they are going to run it by Tricare.

Thanks for letting me vent and if anyone has Tricare just wondering how they were getting them to pay for your surgery!

[sara31 2]

I have Tricare Standard and have had no issues, but I met all the requirements (40 BMI and 2 co-morbidities).

Overall I have only paid about $800 out of pocket.

[MellieW 0]

I have Tricare Prime (same benefits as Standard) and I was approved in 3 days.

These are the requirements for approval through Tricare as per their website;

"TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band®® surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)"
  

They also required me to have an EKG and Pulmonary Function test prior to approval. I'd suggest you do both now, if you haven't already done so, just so you can submit the results with the predetermination paperwork. They're fairly easy to deal with so try not to worry too much.

Good luck!

ETA; I only paid $25.00 out of pocket for my surgery.

Edited October 13, 2010 by MellieW

[ape087 1]

I have tri care prime and beause i was 100lbs overweight they approved me without any additional test.

Judging by your explaination of what they told you, they were just giving you an "in general" answering. Kinda like "oh tri care as an insurance company does cover it" (which they do) but not looking at your case speifically. It sucks that they did that to you.

I would go to your PCM and have them write you a referral to go get a consult (thats where I had to start). They when you get your initial consult the dr's will work with you to see if they can truely see if you qualify with the comorbidities and such.

[jenn79co 13]

I have Tricare Prime everything was covered and fills also.

But refferals are very important. Like the above person said you need to go to your PCM and get the ball rolling. Nothing gets done without it.

[MellieW 0]

You stated in your original post that you have a $1000 deductible so it sounds like you have Tricare Standard.

You only need a referral from your PCM if you have Tricare Prime. Tricare Standard does not require referrals.

Edited October 14, 2010 by MellieW

[MLBL 2]

I have Tricare and was banded in Aug. The current requirments are BMI 35-39 with two comordities or 40+ without comorbidities. I was not 100lbs overweight, only 75-80.

I was also surprised to learn that urinary stress incontinence is one of the qualifying comorbidities. Otherwise, I wouldn't have qualified.