Tricare Prime-- Not overweight long enough?

[srhall13 0]

Hello everyone,

I have Tricare Prime North Region. My BMI is 45 and I am 200% over my ideal body weight for my frame. I have no comorbidities, but everyone over the age of thirty in my family has high blood pressure and diabetes and is morbidly obese. I am 25 and realize that it is just a matter of time before these health problems touch me as well. I live in North Carolina and am being seen by Dr. Johnson at Carolina Surgical Associates in Morehead City, NC. I thought being 200% over my ideal body weight was enough, but my doctors office said that I need to be at least 100lbs overweight for the last 3 years for tricare to approve the surgery. I have only been 100lbs overweight for two years. I have not heard anyone else talk about this requirement and a time limit is not mentioned on the tricare website. Has anyone else run into this time limit problem with tricare?

Thanks

[MarcyLoo 12]

I'm not with Tricare, but my insurance required a FIVE year history of being obese. (I've been obese for maybe 20 years and with the same doctor for that long so proof was easy in medical records)

Have you had a sleep study to diagnose sleep apnea? that may help. You might want to start that now. a year will fly by, and if you can get on cpap for sleep apnea it likely will help you qualify when it's time.

Best of luck! and hang in there!

[Phranp 46]

May I suggest that while you are waiting this "year" that your insurance requires, you have your doc start a supervised weight loss plan or whatever else your insurance requires for the surgery. They make us jump through so many hoops before they do the right thing! It's just awful. But hang in there ... a year will go by faster than you think. Learn everything you can about the band during the wait too.

Now, another thought .... do you think that maybe you can appeal the 3 year/100 lbs thing? You might give it a try. And, the suggestion for the sleep apnea study is really good too.

Good luck to you!

~Fran

[Dave_NW 92]

I have Tricare Prime, and to my knowledge there is no time requirement for how long you've been obese. You may want to print out the Tricare requirements to show them, and ask them how or why they are saying there is a time requirement. When I was initially interviewed by my surgeon's team, I was asked what my weight was at various ages. They saw the trend that I had been progressively overweight for years, but not morbidly obese until a few years ago. So maybe that was enough for them. I was approved within a few days of the submitted request.

Tricare approves people based largely on the doctor's recommendation for surgery. So make sure you convince them of your sincerity, and how you want to avoid the chronic issues your family has. Being proactive in your weight loss may be enough.

Good luck!

Dave

[MarcyLoo 12]

Fran has a really good point...it's a good idea to go ahead and start a supervised weight loss program (in some cases these may just be monthly nutritional counseling, if I'm not mistaken?) In a lot of cases insurance will deny a claim hoping people don't appeal...

Maybe it'll help if some of us talk about what our insurance required?

For me, they wanted a list of diets I've attempted (but no proof other than my handwritten record)

A 5 year history of obesity

Even though my BMI is well over 40 they wanted a comorbidity, so i went for a sleep study and was diagnosed with sleep apnea and put on cpap....but even with this they DENIED my claim. The clinic I'm going to has an attorney they use to appeal, and they did and it was approved 2 weeks later.

[cheryl2586 3,053]

It is tipical for insurance companies to want you to be obese for a certain amount of time. Not sure about tri care though just keep thinking it will come and get your other stuff started.

[L12 13]

Tricare doesn't have a time requirement for being obese, but doctors often have their own requirements; perhaps that is what he is saying? Tricare also doesn't require a supervised weight loss program--be careful about doing this unless it is part of the doctor's program and he counts your beginning weight.

[54Shirley 105]

These are all excellent points ! ! You might want to look up your plan on line, and see what the requirements are. Or,,, simply call them.

If they have no problem, ask them if they know of someone? "A SURGEON" They might suggest a "CENTER OF EXCELLENCE" is where it must be done at..

If that is so,, start looking. Also you can ask anyone on this site if they have used a DR. --- out of ---.....

Good Luck, Hopefully it's just your surgeon, and not the Ins.

Keep in mind if you have been heavy all/part of your life. They might want to know this.

Not necessarily 100LBS., but still overweight, and growing. That's for your own help.

Shirley

[srhall13 0]

Thank you all for your responses!! I talked to a tricare representative this morning and they confirmed to me that there is no required amount of time to be overweight. It is just a matter of necessity. My PCM has written me a letter of medical necessity, so that is not a problem. I have stayed in close contact with my surgeon's nurse, so I am going to call her this afternoon to ask if this is thier policy. I love my surgeon and his staff is great, but if this is his policy than I may try to find another surgeon in the area. It is just frustrating because I am doing everything that they require quickly, but seem to be hitting speed bump after speed bump. Just trying to keep a good attitude!!!

[54Shirley 105]

That is excellent News ! Congrats. on getting that straight.

As far as the Doc's go..... You have to remember, to a lot of them,,, this is just a business. " I KNOW, I HAD ONE LIKE THAT' Your better of moving on,and finding someone new. If !

all it is , is business. I found a new one in northern, Michigan. I had gone to one of Michigan's best. I lost weight, he screwed up ! I regained almost all my weight. So a different Doc. took me in just to see who was full of it "HE WAS !" and they believe me, so I am getting a fresh start all over again, and I have not felt better.

If you have to put up a search on the post op site about a Doc. You will hear if anyone knows of him...

If you do end up looking. Wherever you go, all those notes "visits" can be transferred to the new one. So it's not like you have to go threw it all again, Just so you know.

Great Job,, Very Happy for you, Shirley.

[azbtrfly 2]

Ask that your Dr submit the paperwork, tell him that Tricare does not require it, and if it's his requirement ask for a referral to see a different Dr. As long as you are the 200% overweight, Tricare will approve and within just a few days. They dont have any of the pre-requirements that the other insurance companies have. From start to finish my process took 3 weeks.

[beaner5522 0]

hello, I am tricare prime also, I live in Jacksonville nc,and just got banded on 2/28 .I went to greenville to Dr. Nazari with southern surgical,He is an excellent surgeon. I have never heard of them saying u have to be overweight for 3 yrs either,the only thing you had to do is show them proof for the last 5 yrs of your weight history. So if your dr does not want to help you might want to call down to southern surgical good luck

[USMC Wife 1]

I think its important to know the difference between what TriCare covers/needs and what your surgeon requires. I had the surgery on 1/27, live in the South region and did not have to prove anything regarding weight history, weight loss attempts or specific diets. My surgeon required me to call Tricare directly and find out exactly how and what they covered. Granted they already knew what was covered but they wanted to make sure I understood the process fully. Tricare was billed $47,000 for my surgery (of course they didn't pay that much) but covered every cent of the allowable amount. Good luck and keep pushing if you need this surgery and know you are willing to put the work. Keep looking until you find a surgeon who will do it.

[BRENDYBUSY 0]

Ask that your Dr submit the paperwork, tell him that Tricare does not require it, and if it's his requirement ask for a referral to see a different Dr. As long as you are the 200% overweight, Tricare will approve and within just a few days. They dont have any of the pre-requirements that the other insurance companies have. From start to finish my process took 3 weeks.

[onebadkitty 0]

I am also on Tricare Prime-Remote. I had to have a psychological exam, a BMI of 40 or greater, and I had comorbidities. The doctor submited my paperwork on Friday and by Tuesday I was cleared for the surgery! I didn't have to show a history, do a diet or work out program. I was surprised at how little Tricare required compared to the other insurance companies. I guess that they figure that the health issues that would have outweigh the cost of surgery. I can't imagine them charging 47,000 for the surgery when the average is 16,000 to 20,000. Sounds like a doctor's office trying to rip off the insurance company.