Tricare Prime - Lap Band Denied Again, Again, And Again!

[AZArmyWife36 0]

Well, here I am with a sad look on my face! Tricare denied me again. I didn't meet their requirements even though I have hypertension. My BMI is too low. So, hubby and I looked into it and we are paying out of pocket. I figure I probably have spent at least 10K in my lifetime on diets. So, my pre-op is Tuesday, 28 June and if all is clear and okay then my doc's office will schedule surgery. Wishing everyone luck on Tricare approval! I was hoping with the new rule that I'd get it approved. No luck! Best to all!

[WEESIE 5]

Sorry that they denied you. Glad that you are able to convert to self pay.

[AZArmyWife36 0]

Sorry that they denied you. Glad that you are able to convert to self pay.

Thanks so much!

[azbtrfly 2]

How close are you? Tricare requires you to have 2 health problems and be under or be 100 lbs or more overweight.They denied me the first time but I was close enough that I gained a few lbs and then the nurse handed me a box of books.< /p>

[LVGirl 4]

What new rules are there? I also have Tricare Prime, just had surgery 4 weeks ago and it was still 100+ lbs overweight and a co-morbidity (I had hypertension as well). Where are you located?

I'm sorry for your denials, but very good that you are able to self-pay.

[azbtrfly 2]

I heard that they were changing it to a bmi of 40, instead of the confusing 100 lbs over.

[amjcal 5]

I think you should go to a different surgeon in your area maybe they are submitting the paper work in correctly. Its worth a try. I have a high BMI with no co-morbidity's. I was approved the next day the problem was the refferal and the surgeon a complete mix up is why they denied me at first. I would seriously go to a different surgeon to make sure the paper work is submitted correctly before you pay out of pocket. We love are soldiers and it sounds like he is very supportive, my husband is too!! I wish you the best of luck!

[54Shirley 105]

I would go to someone else. put on ankle weights, then put some on your calve. (YOUR NOT THE FIRST PERSON TO DO THIS, AND "YES" I AM SERIOUS.) put some heavy stuff in your pockets, have your husband tape ankle weight to your back, drink all the Water you can. You only need to raise your BMI.

Comorbidities: Are your knees hurting you, feeling stiff in the morning or after sitting for a while? sure they are. that's one.

No children, but you are trying. That's a big one.

Can't sleep at night, I have to sleep sitting up in a chair for your breathing. that's another one.

These are all possibilities, that can be fixed with weight loss.

Knowledge in this Dr., Ins. thing is vital.

Seriously you take some of this into consideration. There going to weigh you, not strip you.

[Drlnangel 0]

I am in Texas and tried about 2 years ago to get the surgery with Tri-Care, they denied me. BMI too low. I believe at the time you had to be 200% of your ideal weight if you had no Co-Morbities, which I don't. I have heard that tri-care has changed their rules to a bmi of 40 but I'm not sure. I am very close (5-10lbs) to being that 200% over what my idea weight is suppose to be, so this time I was approved immediately. It might be worth it try another doctor or to call your tri-care office directly and ask what the problem is. There should be one on post or someone should be able to tell you who to call to find out what the problem was. Not sure if any of that will help but good luck

[Dave_NW 92]

I don't know if Tricare has OFFICIALLY changed their requirements. They are quite specific about what they will cover, and what they won't, based on the Medicare standards. The following is taken directly from the Tricare website:

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

"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)"

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

If you don't fall within these limits, Tricare will probably deny your request. if you DO fall within these limits, then something your surgeon's office is requesting is out of line. If you have any doubts, call Tricare directly and talk to them about what they will and won't pay for, and why you're being denied. This surgery is expensive, but there is no reason to pay for it if you don't need to.

Good luck!

Dave

[stateofzen 46]

I would go to someone else. put on ankle weights, then put some on your calve. (YOUR NOT THE FIRST PERSON TO DO THIS, AND "YES" I AM SERIOUS.) put some heavy stuff in your pockets, have your husband tape ankle weight to your back, drink all the Water you can. You only need to raise your BMI.

Comorbidities: Are your knees hurting you, feeling stiff in the morning or after sitting for a while? sure they are. that's one.

No children, but you are trying. That's a big one.

Can't sleep at night, I have to sleep sitting up in a chair for your breathing. that's another one.

These are all possibilities, that can be fixed with weight loss.

Knowledge in this Dr., Ins. thing is vital.

I seriously you take some of this into consideration. There going to weigh you, not strip you.

I know people do this, but I wouldn't encourage it. It is insurance fraud and it is illegal. At least send your encouragement to commit a federal crime (Tricare as the insurance) in a PM.

[54Shirley 105]

I no it's illegal ! But ,,, has she paid her dues for that Ins.? I'm sure she has.. So if you need medical care, and because of their contracts, your not going to get it, is not fair either.

They are not going to go broke. They are in the business to make money,. and they do.

It's far better for the patient to even be considered by a Giant like them. Not just say NO ! to the Patient.

For me to say Gee I'm really sorry to hear that is almost useless. She is trying, and trying, and still getting the door slammed in her face.

She could do this, and get by, and they would never miss it.

I'm not into this stuff myself, but I saw my Ins. company get ripped off for thousands from a incompetent Surgeon, who could care less even about the patient, once he got paid. So we both got ripped off, the Ins. company didn't seem to mind, and 5 yrs. later, he is still ripping them off BLIND.

So, I know it's deceiving, but other then that. Why shouldn't she be able to do this if she needs it.

[AZArmyWife36 0]

Wow! Thanks to everyone that has replied! I love the passion and sincerity of everyone! My BMI is 35 and the new rule will cover BMI from 35 - 40 and above. My doctor is one of the best and has done everything to help me out. I'm going to wait another month and try one more time. I heard from someone very helpful today that the new ruling might take affect at the end of July. So fingers crossed! Again, thank you for all the support! Many losses to all and happy lives!!

[azbtrfly 2]

Sometimes when there's changes the people denying the claims don't know of them. May help giving them a call.

[stateofzen 46]

I no it's illegal ! But ,,, has she paid her dues for that Ins.? I'm sure she has.. So if you need medical care, and because of their contracts, your not going to get it, is not fair either.

They are not going to go broke. They are in the business to make money,. and they do.

So, I know it's deceiving, but other then that. Why shouldn't she be able to do this if she needs it.

Hi Shirley-- I know you are trying to be helpful and agree that the insurance game isn't fair to us consumers-- I absolutely will not argue with that I just disagree that it's good to publicly encourage people to commit a crime: it's more than lying, it's lying you can be punished for financially and it's a lie that hurts everyone else who doesn't lie. That doesn't seem fair either. It's a bad situation, all around-- well, for everyone except the insurance giants I guess.