Tricare-Triwest Issues

[EzekielsMommy 0]

So a little history since this is my first post... I have been overweight since I was 5 years old and I've tried almost EVERYTHING you can think of. It took us 7 years to conceive with our son and when he came out, he had complications and needs a feeding tube until he can eat on his own. I really think that me being overweight and having diabetes contributed to all the complications.....

Well...I finally sat down with my PCP and he insisted I get a lapband...I didn't know Tricare covered it and he instantly put in a consult....

fast forward to today......

I had my seminar and my one on one appt with the doctor. He evaluated me and told me that my diabetes is extremely out of control (A1C: 11.5) and he thinks that with the lapband i'd be better...He wanted me to get the gastric bypass but I insisted that all I needed was a boost or a tool to help me and I can do the rest of the work....

To my understanding TRICARE covered if you had a BMI of 40 with one or more comorbities. They measured me at 4'6 and 180lbs. So my BMI was exactly at 40. I have type II diabetes, hypertension, infertility and PCOS. So i was super excited with the surgeon told me that i am an excellent candidate for surgery.

WELLLLLLL....

As I was checking out...the lady told me that TRICARE/TRIWEST doesn't go by BMI but they go by weight. I have to be 100lbs over my ideal weight and with one comorbity. WTF?! First they tell me that my ideal weight for my height is 99, which when I checked through the Met-Life chart my ideal weight for a SMALL FRAME (which I think im a small frame if im 4'6) is 76-102. I dont know what tricare uses to determine someones ideal body weight..PLEASE HELP...

I came out of the building with the surgeon telling me he will still request it...if it gets denied to appeal it.........this saddens me.

[Rsilversea 2]

Have you contacted your insurance company? Tricare has changed their policy since I had it done a year ago. Have your surgeon put in for it but contact your Tricare rep. Don't get discouraged. I was 100 lbs overweight with no comorbidities and was covered. Again, their policy has changed and I think it goes by BMI now but your rep will know.

[xlstan 2]

Well, here on the east coast I have Tri-care. I'm retired Navy and use Tri-care standard. I can tell you that here on the east coast, it's as others said... 100 pounds over ideal weight, BMI of 40-45, OR.... less than 100 pounds/lower BMI but have co-morbidities such as HBP, diabetes, etc...

I can also tell you that insurance wise, the process here has been fairly simple. My problems have been with doctors communicating with other doctors, giving their blessing, etc...

I can also tell you that my doctors' office here is very happy with Tri-care and they told me it is highly unusual to get a denial from them. I did not get denied; approved first time through.

Hope that helps, and if you have any questions for me, let me know!

Stan

[LVGirl 4]

I am on the west coast and have Tricare. My process has been very fast and I am hoping to have an approval by next week. I was told by my doc and Tricare rep that you need to be a) 100 lbs overweight WITH a co-morbidity that they have listed on their website (I am 125 over and have hypertension...you have 2 that you listed but may be short on the weight); or 200% overweight. My doctor goes on the high end of what your ideal weight is because that is what most insurance companies do. I wish you luck!

[ksquires2005 0]

I to have tricare west and was told that i had to be 100+ over with a bmi of over 40. I only starrted this process back at the end of oct of 2010 and have gone through every hoop that they wanted including the 6 months of being on a supervised diet and seeing a nutrisionist during that 6 month period, and have gone through the all the pre-op testing requirements, which they approved, but they won't approve the surgery. I know how you feel about being discouraged as I am to. I'm a little lost with what to do now. I'm going through a different office instead of through balboa here in San Diego. but they haven't called me or anything. I'm a little bummed and irritated at the same time. Am thinking of going back to talk to my PCP, but they always try to sucker me into doing other checkups that I don't want to have done. I just want this process to be done and over with because it is stressing me out so much these days.