Tricare - Aggravated

[GoSetReady 0]

I'm wondering if anyone else is having to complete the following checklist from their PCM with Tricare Prime? I'm actually Tricare overseas Prime Remote. I just spent the entire AM on the phone trying to explain that this is not the requirements per the Tricare Manual Chapter 4 Section 13.2. After I couldn't get a clear explanation on how they came up with this checklist through International SOS (3rd party used by Tricare Prime overseas for referrals) I spoke with the regional Tricare office in Germany. I was informed they came up with this checklist so "not just anyone" could get the surgery. I was then informed I could just go to the PCM and have them submit a letter addressing my Hx of attempts, comorbid Dx and etc. But was informed approval was on a case by case basis and if denied could appeal. (Duh Rolling eyes) So aggravated that the requirements are not the same across the board for Tricare Prime. I'm 5'1 and approx 198lbs with sleep apnea. I'm aware that b/c I'm not 100lbs overweight according to Metlife charts I will be denied although my BMI is and has been above 35 with the comorbidity for >5 years. I have tried every diet known to man as I'm sure you all did too. I loose the weight but it never stays off. We have been overseas now for 6 years but I don't have the documentation they are requesting in my medical record b/c we are remote (not at a MTF) and these diets are not covered by Tricare therefore paid for out of pocket. I also recently read in the Fed Recorder that the requirements will change from the Metlife Chart to BMI on 3-16-2011. Anyone else aware of this and have spoken with Tricare in regards to the change. Right now I'm afraid that I've stirred the pot too much and will be denied just for demanding where they came up with this checklist. If anyone has a better contact through Tricare I'd love the name and number. Any advice is appreciated. Wish me luck. I plan on seeing a PCM on the 16th of March and keeping my fingers crossed. 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

_________________________________ __________________________