Newbie from San Diego, CA

[Pashion 7]

Hello All,

I am new to this forum and I have questions regarding getting approval for the Lap Band by Tricare Prime and I am hoping that someone out there can give me some insite on this because I am starting to get discouraged. My first question is I was told by the nutritionist that because my BMI is 38.6 Tricare will prob deny me. But I thought that as of 03/16/2011 Tricare Prime was approving the lap band if your BMI is 35-40 with one co-morbit. Has anyone with a BMI under 40 been approved by Tricare Prime? My other question is the insurance coordinator at the surgeons office stated that Tricare is the hardest insurance to get approval from and that there is a chance that Tricare will approve me but only if I go to a local MTF for the surgery she explained that this has happened to other Tricare patients in the past. My local MTF is Balboa hospital and I would prefer not to go the there if I didn't have to. Has anyone been approved by Tricare but only if they go to a MTF for the surgery and not to a civilian hospital?

[formykids2 4]

I have tricare prime and was just approved with a bmi lower than 40. I did have a bmi over 35 and comorbidities and i had no issues at all getting approved. Because of the new change some people are a bit confused as to what qualifies now. I did a post on this in the insurance section and posted the link to the tricare manual and the section that outlines the new rules. Please feel free to pm me if you have questions!

[Pashion 7]

I have tricare prime and was just approved with a bmi lower than 40. I did have a bmi over 35 and comorbidities and i had no issues at all getting approved. Because of the new change some people are a bit confused as to what qualifies now. I did a post on this in the insurance section and posted the link to the tricare manual and the section that outlines the new rules. Please feel free to pm me if you have questions!

Thank you so much for responding back, sometimes it gets discouraging when you tell people you have Tricare and they look at you as if you are from out of space. Do you know if Tricare will require me go to the MTF instead of my civilian hosptial to have the surgery done. Are you using a MTF or civilian hospital?

[formykids2 4]

We do not have a bariatric program here so I am going to a civilian. I have heard of people not going to mtf though if there is a wait list. The thing to do I would think is just try and if they deny, fight it then. Make sure you have a documented trial with your doctor (new requirement), and I was required to have an h pylori and either pulmonology or cardiac clearance. Everything was sent in and it was missing the h pylori results and that made my approval take longer so make sure you have everything ready when they send it out. Have you already gotten your consult with the civilian provider? If they were willing to give you the consult to begin with I cant see any reason that they would turn you down for them.

[formykids2 4]

I just sent you a message with my process so far. Hope it helps!

[Pashion 7]

We do not have a bariatric program here so I am going to a civilian. I have heard of people not going to mtf though if there is a wait list. The thing to do I would think is just try and if they deny, fight it then. Make sure you have a documented trial with your doctor (new requirement), and I was required to have an h pylori and either pulmonology or cardiac clearance. Everything was sent in and it was missing the h pylori results and that made my approval take longer so make sure you have everything ready when they send it out. Have you already gotten your consult with the civilian provider? If they were willing to give you the consult to begin with I cant see any reason that they would turn you down for them.

I have done my consult with the surgeon and the psych eval, now I am just waiting for orientation on the 17th of this month and a diet class these are required by the surgeon not Tricare. What type of documented trail do I need to have? This is exactly what I am talking about, I called Tricare three times and nobody said anything about having an h pylori, pulmonology or cardiac clearance done. What is h pylori? They did mention having documented weight loss but could not specify what type of weight loss documentation they are looking for and when I asked for how many months they could not tell me that either.

[Pashion 7]

I just sent you a message with my process so far. Hope it helps!

Your message was very helpful thank you so much and good luck with your surgery, I know you will be successful.

[Dave_NW 92]

I have Tricare Prime, and wasn't required to have those other tests. Here is my timeline from referral to approval:

Referral from PCM to WL Surgeon 19-Aug-10

Attended Surgeon's Mandatory WL Seminar 25-Aug-10

1st Consult - Surgeon/Staff 29-Sep-10 (Surgeon, Physician, Nutritionist, and Psych Eval, all on the same day)

Lab Work Completed 1-Oct-10

Endoscopy 14-Oct-10

Surgery Request Submitted to Insurance 15-Oct-10

Surgery Approval Received from Insurance 20-Oct-10

As you can see, it was basically three weeks from the consult to surgery approval. I disagree with what you're being told about Tricare being hard to get approval from. Everything I've experienced, and been told, says they're one of the easiest to get approval from, if only because they don't require a six month managed diet.

I live in Washington state, and went to a civilian surgical center. The closest MTF to me is further away than the civilian hospital I used. Tricare didn't care. The only reason they would have insisted I go to an MTF would have been if I'd wanted to have sleeve surgery instead of lapband. (For reasons I don't understand, that's covered at an MTF, but not at a civilian hospital.)

If you have questions, call Tricare and ask them directly. Getting rumors and suspect opinions will only frustrate you.

Good luck!

Dave

[AZArmyWife36 0]

Hello All,

I am new to this forum and I have questions regarding getting approval for the Lap Band by Tricare Prime and I am hoping that someone out there can give me some insite on this because I am starting to get discouraged. My first question is I was told by the nutritionist that because my BMI is 38.6 Tricare will prob deny me. But I thought that as of 03/16/2011 Tricare Prime was approving the lap band if your BMI is 35-40 with one co-morbit. Has anyone with a BMI under 40 been approved by Tricare Prime? My other question is the insurance coordinator at the surgeons office stated that Tricare is the hardest insurance to get approval from and that there is a chance that Tricare will approve me but only if I go to a local MTF for the surgery she explained that this has happened to other Tricare patients in the past. My local MTF is Balboa hospital and I would prefer not to go the there if I didn't have to. Has anyone been approved by Tricare but only if they go to a MTF for the surgery and not to a civilian hospital?

I as well was just approved with a BMI of 35 with one co-morbit with Tricare Prime. I've been denied 3 times and with the new ruling I was approved the day after it was submitted. No MTF here at Huachuca. But I bet if you look into it more you'll be on your way to getting approved. Best of luck!!

[Pashion 7]

I as well was just approved with a BMI of 35 with one co-morbit with Tricare Prime. I've been denied 3 times and with the new ruling I was approved the day after it was submitted. No MTF here at Huachuca. But I bet if you look into it more you'll be on your way to getting approved. Best of luck!!

Thank you. When is your surgery date? Did you need to submit proof that you have tried other weight loss procedures and nothing worked? What reasons did they give you for your previous denials? I am currently waiting for my previous doctor to send my medical records to the surgeon showing my co-morbit then they will sumit it to Tricare Prime for approval. I am currently at 38.6 BMI but my previous doctor was not very attentive so I had to switch to a new doctor who I have only seen twice since Sept. she does not have as much medical history on me as my previous doctor. Some people who have Tricare Prime had to have blood test and and a endoscopy done before Tricare would approve it, did you?

[Pashion 7]

I have Tricare Prime, and wasn't required to have those other tests. Here is my timeline from referral to approval:

Referral from PCM to WL Surgeon 19-Aug-10

Attended Surgeon's Mandatory WL Seminar 25-Aug-10

1st Consult - Surgeon/Staff 29-Sep-10 (Surgeon, Physician, Nutritionist, and Psych Eval, all on the same day)

Lab Work Completed 1-Oct-10

Endoscopy 14-Oct-10

Surgery Request Submitted to Insurance 15-Oct-10

Surgery Approval Received from Insurance 20-Oct-10

As you can see, it was basically three weeks from the consult to surgery approval. I disagree with what you're being told about Tricare being hard to get approval from. Everything I've experienced, and been told, says they're one of the easiest to get approval from, if only because they don't require a six month managed diet.

I live in Washington state, and went to a civilian surgical center. The closest MTF to me is further away than the civilian hospital I used. Tricare didn't care. The only reason they would have insisted I go to an MTF would have been if I'd wanted to have sleeve surgery instead of lapband. (For reasons I don't understand, that's covered at an MTF, but not at a civilian hospital.)

If you have questions, call Tricare and ask them directly. Getting rumors and suspect opinions will only frustrate you.

Good luck!

Dave

Hello Dave,

WOW!!! you were approved quickly...I have called Tricare Prime four times and under the new rules you can have a BMI of 35-39 with one co-morbid but now they also require documentation from your PCM stating that you have tried other weight loss programs or meds that did not work. The surgeon has to write up the request stating that this procedure is for health reasons and not for weight loss (how crazy is that) and that nothing else in the pass has worked. What I thought was strange is that there is nothing in Tricare's policy that says how many months of proof they are requiring and they never mention anything about blood work or having to have an endoscopy done. Why is that I wonder? How did you know that lab work and an endoscopy was needed? Like I said I have called Tricare four times and not once has any Tricare rep mentioned that to me. I wonder if I will be denied stating that I need to have these procedures done first.

One other thing I almost forgot to mention. According to Tricare if there is a surgeon at the MTF that is available when the request is submitted and surgery can be done within 30 days Tricare will request that I go to the MTF. They stated that is with any type of procedure because Tricare is military they will always refer to MTF first if possible.

Was you BMI over 40?