Tricare Approval

[azbtrfly 2]

I'm 5'4" and 245 lbs with a BMI of 42, my doctor submitted my paperwork on last Friday and I was declined today. They said they needed more documentation, and that I dont have the comorbs that I need. I thought that as long as my BMI was 40, I didn't have to have comorbs, but it sounds like they are still using the 200% rule.

I have back problems, high cholesterol, depression and have to take sleeping pills to sleep at night, but none of that counts.

The Metropolitan weight chart leaves so much to guess at, Small frame is 114-127, so 200% would be 228 and medium is 124-138 or 248. I'm kind of inbetween a small and medium frame, my fingers do overlap slightly around my wrist. Do I really have to gain 3 lbs and then have them resubmit the paperwork?

5' 4" 114-127 124-138

[GlitterG 1]

I'm 5'4" and 245 lbs with a BMI of 42, my doctor submitted my paperwork on last Friday and I was declined today. They said they needed more documentation, and that I dont have the comorbs that I need. I thought that as long as my BMI was 40, I didn't have to have comorbs, but it sounds like they are still using the 200% rule.

I have back problems, high cholesterol, depression and have to take sleeping pills to sleep at night, but none of that counts.

The Metropolitan weight chart leaves so much to guess at, Small frame is 114-127, so 200% would be 228 and medium is 124-138 or 248. I'm kind of inbetween a small and medium frame, my fingers do overlap slightly around my wrist. Do I really have to gain 3 lbs and then have them resubmit the paperwork?

5' 4" 114-127 124-138

I am not sure why they would have denied you. I am 4'11" and started the process at 228. Did you have a private PCM or are they at the base hospital?

I asked my PCM about the procedure and he then referred me to the bariatric surgeon for consultation. After seeing the surgeon his office submitted the surgery request for approval.

Can you possibly contact Tricare and ask why the request was denied?

Sorry you are having to go through this aggrivation - I would have the Dr resubmit for approval.

[Mimilou2004 13]

Eat a big meal, drink lots of Water, don't tinkle ahead of time, and put rocks or rolled coins in your pockets and weigh in again!!!! Also have the doc specify you are big boned....it helps. 3 pounds is a small price to pay, in my opinion.

Good Luck, Mimi

[Adrea 0]

I'm 5'4" and 245 lbs with a BMI of 42, my doctor submitted my paperwork on last Friday and I was declined today. They said they needed more documentation, and that I dont have the comorbs that I need. I thought that as long as my BMI was 40, I didn't have to have comorbs, but it sounds like they are still using the 200% rule.

I have back problems, high cholesterol, depression and have to take sleeping pills to sleep at night, but none of that counts.

The Metropolitan weight chart leaves so much to guess at, Small frame is 114-127, so 200% would be 228 and medium is 124-138 or 248. I'm kind of inbetween a small and medium frame, my fingers do overlap slightly around my wrist. Do I really have to gain 3 lbs and then have them resubmit the paperwork?

5' 4" 114-127 124-138

What do they mean by more documentation?? I am in the exact same situation except that I am 5'5, I have my first appointment with the surgeon on Monday. I have weight records from when I was a baby up proving that I have been overweight since I was 5, and I have a family history of EVERYTHING so I am hoping real hard that, that will help me out. You can appeal the decision though I don't know how that works. Good luck and I hope you get approved!!!!

[doodlebugsmom 9]

I have heard others mention on the boards that some of the regions of Tricare are harder then the others. I am in region South and I was approved pretty easily. However, I have heard that North is more difficult but not impossible so what ever region you are in dont give up. You have to keep pushing forward and get medical records and diets you have tried what ever you think that increase your odds. Best of luck to you.

[Dave_NW 92]

I'm not sure if you've seen it, but this is taken directly from the Triwest Benefits website pages:

Gastric Bypass

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)

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity

*******************************

So maybe you need to evaluate your stats? A BMI of 40 isn't all that is required. If you want to use the 100 pounds over ideal weight ruling, then you need to have at least one of the listed comorbidities.

Dave

[amberakamom 13]

Just have them document the things you mentioned, and you should be fine. My approval was really smooth with tri-care.

[azbtrfly 2]

Well I ended up gaining 10 lbs and then tried again, got approved no problem. They also switched my stats from a medium frame to a small frame. It looks like mid-March they are switching to the BMI method, that will be much easier.

[doodlebugsmom 9]

Well I ended up gaining 10 lbs and then tried again, got approved no problem. They also switched my stats from a medium frame to a small frame. It looks like mid-March they are switching to the BMI method, that will be much easier.

So happy for you. I am a tricare patient myself so I have had years of dealing with them. I have surgery next week. I am doing the happy dance for you.

[AZArmyWife36 0]

Well I ended up gaining 10 lbs and then tried again, got approved no problem. They also switched my stats from a medium frame to a small frame. It looks like mid-March they are switching to the BMI method, that will be much easier.

Hi,

I was denied twice from Tricare a couple years ago. Where did you hear about it being switched to the BMI Method? Any information is greatly appreciated.

Thank you,

Brenda

[GoSetReady 0]

Hi,

I was denied twice from Tricare a couple years ago. Where did you hear about it being switched to the BMI Method? Any information is greatly appreciated.

Thank you,

Brenda

I'm in the same situation you are in. I happen to be very short 5'1". With the Metlife table I do not meet requirements per current Tricare requirements if they went off BMI I'm at 37.4. Go figure. They are changing to BMI effective 3/16/2011 per conversation with Medical Director for Tricare Dr. Barry Cohen. He also told me they are going to start requiring documented history of weight loss attempts and history of obesity. He said the new policy should be on the Tricare site in a few months. For now you can go to the following website for the information. http://federalregister.gov/a/2011-3207 I'm planning on going to my PCP this week with the new BMI requirements before Tricare changes any other requirements on their site. Keep me informed of your progress. Interested in others success with the new BMI change.

[AZArmyWife36 0]

I'm in the same situation you are in. I happen to be very short 5'1". With the Metlife table I do not meet requirements per current Tricare requirements if they went off BMI I'm at 37.4. Go figure. They are changing to BMI effective 3/16/2011 per conversation with Medical Director for Tricare Dr. Barry Cohen. He also told me they are going to start requiring documented history of weight loss attempts and history of obesity. He said the new policy should be on the Tricare site in a few months. For now you can go to the following website for the information. http://federalregister.gov/a/2011-3207 I'm planning on going to my PCP this week with the new BMI requirements before Tricare changes any other requirements on their site. Keep me informed of your progress. Interested in others success with the new BMI change.

Wow! That's amazing! Thanks for the info! I have an appt with my PCM on Monday for referral. I'll keep you updated! Good Luck!!

[Joleen 3]

Wow! That's amazing! Thanks for the info! I have an appt with my PCM on Monday for referral. I'll keep you updated! Good Luck!!

Sorry to hear that, with your sleeping problems ask your doc. to check for sleep apnea, the odds are high you might have at least mild and that would qualify you. I have a low BMI and have Tricare Prime. My hubby is Active Duty and the said I didn't need any comorbidities, but I have heard it helps. Make sure you call Tricare yourself and ask to speak to the WLS person for insurance auths. Not just a regular authorization person, they will tell you say to everything without throughly checking!!!!!

Good Luck,

Joleen

[bzbrown 1]

My tricare approval also went smoothly, I have high blood pressure and 48.4 BMI, surgery is scheduled for a week from yesterday. My only concern is at seemingly the last minute Triwest announced they would not be covering the surgery facility I was originally planning to use, so now I have to use one that's covered and is nearly 2.5 hours away. It makes no sense to me, but I really like my surgeon and her staff so I don't want to have to do the process over again, since they can work with me at the other facility still. I'm thinking that drive home next week is going to be "interesting" lol...

[LaToya 0]

did anyone with tricare have to do six months of dieting?