Tricare, ONLY 100lbs over wt w/ comorbidity

[Lilpeach_059 0]

Hi,

Anyone that has been approved and is 100lbs overweight and has a comorbodity, what was the procedure for informing tricare of the comorbidity? I heard that the person from the surgeons office will call you and ask, and if you say yes then thats it. If this was true for you please post your experience here! thanks!:smile:

[minpinmom 2]

I am 100lbs over and NO co morbidities - I was approved no problem. I believe you have to have the co morbidities if you are less than 100lbs.

[Boo Boo Kitty 3]

I am not trying to help you cheat the system, but co morbidies include problems with knees, back ect. It may not be as hard as you think!

[my2parrots 0]

I know you must have your primary physician make the referral, otherwise Tricare will not approve. I would imagine that's the source for co-morbidities, but I'm not sure. When I stop and think about it, Tricare has been paying for my prescriptions for High Blood pressure and cholesterol drugs for the past 10 years. If they need more proof than that, they're really screwed up.

My surgeon's office attempted to get approval before I could get in to see my doctor for the referral, and I was denied. I finally got in to see my primary physician on Jan 31, and the surgeon's office called me Friday and said the referral is all they're waiting for. I'm anxious to get this moving!

Keeping my fingers crossed!

[Linda Davis 0]

My primary has made the referral and Tricare called me the next day and approved the referral! Yea! I hope that is a good sign I am going to the seminar on Feb 19 and than I hope I will find out if I will be approved. I am just at bmi 35 at 5'4" and 205. I have this apple thing going on(sigh). I have several co-morbidities:High blood pressure, severe sleep apnea(w/cpap), ostoporsis, degenerative arthritis, gerds, high blood cholesterol.

I am seeing Dr Daryl Steward, Denton TX. The option I am shooting for is the 75+lbs and above co-mor's. Does anyone have any advice? btw when Tricare recently went with approving the lapband they back dated the approval to Feb of 07. so it seems anyone who was with Tricare and self paid might have a case for some reinbursment?Thanks so much.

Linda

[Lilpeach_059 0]

I am 100lbs over and NO co morbidities - I was approved no problem. I believe you have to have the co morbidities if you are less than 100lbs.

Correct me if Im wrong...but if your starting H/W was 5'4 254lbs, then you are 200% over your ideal wt for your height, which happpens to be 114-127. At 200%, then no comorbidity is required...is this your correct starting Ht and Wt?

[minpinmom 2]

You would be correct - well, the weight fluctuates, but all in all, that is close enough. I am medium frame, so 124-138 is what my weight is supposed to be. In reality, the 200% is supposed to be on both ends of the weight scale, according to Tricare. So, if you take the low end

124 X 200% = 248 (here, I am ok)

The high end is

138 X 200% = 276 (Which I don't meet)

So, your guess is as good as mine. Here is the Met Life link if anyone wants it.

Met life ideal height weight tables references

My approval says approved due to Morbid obesity - doesn't list any details.

[minpinmom 2]

Also, just to point out, I had severe sleep apnea years ago and had major surgery to correct it and I had CHILDHOOD Asthma. I know the Dr. put those in the letter to the Dr., but they are not affecting me now. The ONLY thing submitted was a letter from the surgeon - no documentation. Who knows, maybe Tricare is so new to this process and they are moving people through pretty quick. Maybe they aren't trained yet on what the standards are, my suggestion, get your paperwork in asap, I haven't heard of anyone being rejected yet.

[Startingover! 0]

Hi everyone, I am also beginning my lap band journey w/Tricare! I have had my referral from my PCM, which Tricare approved in 1 day, I had my consult w/the surgeon, I've had my psych appt and tomorrow I have my dietician appt and my pre-op class. So tomorrow the surgeon will submit my paperwork to Tricare. So I should know something by the end of the week. But the surgeon's office is 100% sure that it will be approved. They are proceeding like it has already been approved, short of giving me a surgery date. I only had my consult w/him last Wednesday, that's how fast it's moving. The surgeon said I should be banded within a month from last weeks meeting. I'm trying not to get too excited until I hear back from Tricare though.

One more thing, the surgeon did not require any documentation about any co-morbidities. Which was strange to me. They simply took my word for it. Go figure.

[Lilpeach_059 0]

You would be correct - well, the weight fluctuates, but all in all, that is close enough. I am medium frame, so 124-138 is what my weight is supposed to be. In reality, the 200% is supposed to be on both ends of the weight scale, according to Tricare. So, if you take the low end

124 X 200% = 248 (here, I am ok)

The high end is

138 X 200% = 276 (Which I don't meet)

So, your guess is as good as mine. Here is the Met Life link if anyone wants it.

Met life ideal height weight tables references

My approval says approved due to Morbid obesity - doesn't list any details.

Oh, I see...I used the small frame. (b/c I heard u get to pick your frame:confused:) Anywho, since I am only 20 years old...has anyone seen a chart for ideal weight for a 20 y.o. female patient at 5'5?? I have found some, but they are difficult to read...

[minpinmom 2]

My Dr. measured my wrist and said I was medium framed, but to tell you the truth, I am not sure what they sent to the insurance. Maybe they said small frame and I got in through the 200%, or maybe since I had co-morbidities in the past, they wrote them in the letter. I do know, they didn't require me to do a psyh or nutritionist, I even did the psych and they didn't send it in. And they didn't send in any docs with it, just a simple letter from the surgeon.

[aculberg 0]

How did I miss this thread!? lol So, most surgeons are just taking people's word on their co-morbidities, and putting that in a letter to Tricare?? I thought they had to submit your medical records and all that jazz?? I feel like I'm right on the cut off to get approval, almost the 100lbs over, with hypothyroidism, high cholesterol, stress urinary incontinence...but nothing too serious! I meet with the surgeon for my initial consult in a couple of weeks, and might just have to fill my pockets up with quarters to qualify! :behindsofa: I really wish I knew just what Tricare looked at for the approvals...sigh

[Linda Davis 0]

Hi I have not been on the list for a while because Dr Stewart and I decided to go with rny instead of the lapband. I had surgery on june 2 and am doing great. As to Tricare I had to provide med records from my Doc and have either sleep Apenia, high blood pressure uncontroled with medication, or diabeties. Because I turned 65 in May my status changed to Medicare primary and Tricare secondary. I hope this helps someone. warm regards

Linda

[Jesusislove 26]

Hi, if you are 100lbs overweight you must have a co-morb. If you are 200% of your weight you need no co-morbs. You never know who will get your records at tricare and to send it in with nothing(co-morbs) may get you a denial. My doctor did the whole nine yards and basically guranteed me approval, I was approved in 2 1/2 days. Mine was high blood pressure and knee pain. Yes my records and file was sent in. This is in the tricare prime manual, now if you are champus, it maybe slightly different.

[babyka16 0]

You would be correct - well, the weight fluctuates, but all in all, that is close enough. I am medium frame, so 124-138 is what my weight is supposed to be. In reality, the 200% is supposed to be on both ends of the weight scale, according to Tricare. So, if you take the low end

124 X 200% = 248 (here, I am ok)

The high end is

138 X 200% = 276 (Which I don't meet)

So, your guess is as good as mine. Here is the Met Life link if anyone wants it.

Met life ideal height weight tables references

My approval says approved due to Morbid obesity - doesn't list any details.

know that you wrote this over a year ago but i wanted to know how you find out your ideal weight. i tried what you did and come up with wird numbers?! im 5'5 and 264 as far as i know im a medium frame. i was denide from tricare because i dont have any co-morbitidys but im a 100 pounds over weight. im going in to see my pcm on monday and see if we can find something to get me approved. any help?

karen