Tricare

[GoSetReady 0]

Wondering if anyone else was required to submit to Tricare - History of 6 mos medically supervised diet/exercise and 5 year history of 100lbs over ideal weight by PCM before you can get a referral? Also, has anyone read that effective March 16, 2011 Tricare will now accept BMI vs. Met life ideal weight?

[Mimilou2004 13]

Tricare has NONE of those requirements.

[thompsonfalls 1]

I just got approved with Tricare after the 4th denial. They used BMI and Met life ideal weight and a life threating condition. Whew..was a long process. I have been fighting them for 6 months but my surgery date in the 21st.. Hang in there and yes, it might take a few months but hopefully it will be worth it..

Wondering if anyone else was required to submit to Tricare - History of 6 mos medically supervised diet/exercise and 5 year history of 100lbs over ideal weight by PCM before you can get a referral? Also, has anyone read that effective March 16, 2011 Tricare will now accept BMI vs. Met life ideal weight?

[GoSetReady 0]

I just got approved with Tricare after the 4th denial. They used BMI and Met life ideal weight and a life threating condition. Whew..was a long process. I have been fighting them for 6 months but my surgery date in the 21st.. Hang in there and yes, it might take a few months but hopefully it will be worth it..

I just spent the morning on the phone with International SOS. They approve all our referrals for Tricare overseas. They told me it is done on a case by case basis. I've spoken to Tricare in Germany and was informed that they set these conditions for overseas dependents so "not just anyone" can get the surgery. I just left a message with a Dr. Barry Choen (sp) in VA. Just wondering how the tricare manual can state one thing and a region can require more? It should be the same across the board. So frustrating. Here's the form we are required to have our PCM fill out here.

Step 1: Patient Review (All items must be checked by the PCM and applicable to the patient)

Documented morbid obesity for 5 years. Meets definition; body weight is 100 pounds over ideal weight for height and bone

structure, according to the most 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% or more of ideal weight for

height and bone structure.

List any co-morbid conditions: ________________________________________________________________________________

DEROS date at least 12 months from the anticipated surgical date. Date of DEROS: _____________

Participation in a documented nutrition/exercise program for a cumulative total of 6 months with documented ability to lose 10-

15 lbs within the last two years. (Patient‘s inability to comply with a diet and exercise regimen prior to surgery indicates poor

compliance and an increased risk of adverse outcomes)

Comprehensive evaluation and review of significant medical or psychiatric history by their Primary Care Manager (PCM),

surgeon or mental health professional/counselor indicating good candidacy, readiness for bariatric surgery, and confirmation of

positive family support system.

Education regarding the need for lifelong follow up.

The patient has been advised that TRICARE policy does not cover breast lifts, thigh and arm reduction, and that a panniculectomy

must be deemed medically necessary to be covered by TRICARE.

Step 2: Post-operative Management

Primary Care Manager must acknowledge capability to provide appropriate post operative medical management to include: (all

items must be checked in order to be considered for approval):

Dietary Counseling

Mental Health assessment or referral

Laboratory assessment plan for possible nutritional deficiency

_________________________________ __________________________

[chiefsangel 0]

Wondering if anyone else was required to submit to Tricare - History of 6 mos medically supervised diet/exercise and 5 year history of 100lbs over ideal weight by PCM before you can get a referral? Also, has anyone read that effective March 16, 2011 Tricare will now accept BMI vs. Met life ideal weight?

I am in stateside south region of tricare. I did not have to do any of that. I had to see my PCM have her send in a referral. Then I had to go through about a 3 month period of classes... literally. Had to go to seminars about the Y or the lap band and to support groups and stuff. Had to go to so many different classes, educational things, etc before you could proceed. I also had to get some labs. I did not have to have a chest xray or UGI (but they do require one... I had one for other medical reasons close to my surgery so I did not need another). I was approved very quickly and could have had my sugery within a few months of starting but I had to wait for my husband to get home from deployment. I was told many many many times that if / when I leave the current area that I am in that if I go to another installation that does not do the lap band (as many posts are not doing it yet) that I COULD pay for my fills on my own. I did call tricare healthnet and they could NOT give me a straight answer. They said that the care of the band is not excluded but that it does also not say it is covered. SOOO who knows. I do know from my experiences of being in several different posts, that YES tricare is different region by region. When we were in WA my meds were forumlarly and had no problem with them, then when we come to TN its not and had to go through a bunch of stuff to get my meds.

Its the govt and its always a pain in the @%# but just have to keep going through the system and getting it approved.

[GoSetReady 0]

I am in stateside south region of tricare. I did not have to do any of that. I had to see my PCM have her send in a referral. Then I had to go through about a 3 month period of classes... literally. Had to go to seminars about the Y or the lap band and to support groups and stuff. Had to go to so many different classes, educational things, etc before you could proceed. I also had to get some labs. I did not have to have a chest xray or UGI (but they do require one... I had one for other medical reasons close to my surgery so I did not need another). I was approved very quickly and could have had my sugery within a few months of starting but I had to wait for my husband to get home from deployment. I was told many many many times that if / when I leave the current area that I am in that if I go to another installation that does not do the lap band (as many posts are not doing it yet) that I COULD pay for my fills on my own. I did call tricare healthnet and they could NOT give me a straight answer. They said that the care of the band is not excluded but that it does also not say it is covered. SOOO who knows. I do know from my experiences of being in several different posts, that YES tricare is different region by region. When we were in WA my meds were forumlarly and had no problem with them, then when we come to TN its not and had to go through a bunch of stuff to get my meds.

Its the govt and its always a pain in the @%# but just have to keep going through the system and getting it approved.

Thanks for the response. I'm staying with it and hope to get a referral soon.

[Lcuy 3]

Wondering if anyone else was required to submit to Tricare - History of 6 mos medically supervised diet/exercise and 5 year history of 100lbs over ideal weight by PCM before you can get a referral? Also, has anyone read that effective March 16, 2011 Tricare will now accept BMI vs. Met life ideal weight?

Have talked to everyone I can think of to call with Tricare and Helthnet and it is still not implemented. They are hoping in the next couple of months. I have been denied under the old plan but fit into the new rules. Wish they would hurry .

[melzie_99 22]

I have TriWest (prime) and had no problems getting approval. I am, however, more than 100lbs overweight and have high blood pressure as well as sleep apnea. I have been seeing various PCM's for years about my weight so that may also have helped my fast approval (less than 48 hours). My surgeon's office only required me to go to a 3 hour nutrition class; they offer post-op support groups which I'm looking into and am also going to see a therapist for the emotional aspects of weight loss, but really had very minimal requirements I was given.

[GoSetReady 0]

I believe on the Fed Register site they have a contact person. You might call her. I'm afraid I will be in the same boat as you. Stay with it. Are they aware of the change and that it was to go in affect on 3/16 not in the next couple of months? Good luck!

Have talked to everyone I can think of to call with Tricare and Helthnet and it is still not implemented. They are hoping in the next couple of months. I have been denied under the old plan but fit into the new rules. Wish they would hurry .

[Lcuy 3]

Yes, I have talked to all of them and thier response is that it isn't on the records yet ( or something to that effect). They told me to keep checking and If I didn't hear anything in the next 2 months to contact them and keep checking. It will happen but they are still going to use the Metropolitain Life Tables until this instruction is added. Hang in there and keep them busy by calling and asking all the question. Good Luck to you also!

I believe on the Fed Register site they have a contact person. You might call her. I'm afraid I will be in the same boat as you. Stay with it. Are they aware of the change and that it was to go in affect on 3/16 not in the next couple of months? Good luck!