Tricare Prime approval question...

[gina s. 0]

My insurance (tricare prime) has approved me for four visits to the bariatric center where I'll have the procedure done, but they haven't approved the actual procedure. I know that the bariactic center will send them the referral for the surgery after some of my appointments, but what are the chances that Tricare will deny it? By the way, I weigh 239 and am 5'7'' (don't meet the weight requirement) but I have one co-morbidity....high blood sugar.

[lisachace 0]

Hi there...They may deny it because you usually have to have 2 problems if the BMI is not at the right level. Look on your insurance website and call them and ask them where to go to look for the requirements. Thats what I did and followed that and got mine approved thru my insurance. Hope it goes well for you

[gina s. 0]

Thanks for the suggestions.....the only things that I have ever seen about requirements didn't say you had to have two, but I haven't actually looked any further. I will check it out, but in the meantime if anyone knows for sure could you please let me know? Thanks!

I just keep hoping that since I was approved to see the surgeon that getting approval for the procedure will be a piece of cake....can't get my hopes up though.

[lisachace 0]

Never give up hopes....I know I have Blue Cross and my requirements were first 6 months with your primary doctor on a diet program plan with weighing in monthly. Then the other requirement was 40BMI or greater or if you were less than 40BMI then you had to have two of a list of like 5 medical problems. I hope this helps and good luck insurance is not easy.

[p3photogal 0]

ummm, it really depends on who the reviewer is. They might approve because it's the band and not bypass. Normally the requirement is 100 pounds overweight or a bmi of 40. There is a work around though. have your high blood sugar listed as pre-diabetes or diabetes and they will most likely approve you. They make exceptions for bmi 35+ with diabetes or heart problems in some cases.

[gina s. 0]

I did find a list of the requirements, and it said 100 lbs. over with one co-morbidity or 200% over.....I do have a BMI greater than 35, but I'm not considered 100 lbs. over. One positive is that when I went to the psych eval, the psychiatrist took my family history and said it seemed like I had a good case. Anyway, keep you fingers crossed for me! I won't know until after my consult at Scott and White on the 25th. Thanks for the replies!

[Jesusislove 26]

Hi, I am tricare prime, I had not seen my bariatric doctor. They got the procedure approval before the first visit. I am approved for the visits and the lap-band procedure. My surgery is in April. Tricare does not go by BMI at all.

[ready_2_lose 0]

That is interesting about Tricare not going by BMI. Do you know where I can find a list of some sort about what they are looking for to approve you for the band?

Thanks!

[p3photogal 0]

Heres the info from the tricare policy manual:

Tricare's requirements Gastric Bypass (Surgery for morbid obesity) – Limited Benefit – Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty may be covered when one of the following conditions are met (view Hospitalization Costs):

The patient is 100 pounds over the ideal weight for height and bone structure and has an associated medical condition, such as diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.

The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions. (this is by using the metropolitian weight table.)

Laparoscopic adjustable gastric banding is covered, effective February 1, 2007.

The following are not covered:

Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633).

Gastric bubble or balloon

Gastric wrapping/open gastric banding (CPT code 43843)

Unlisted CPT codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

[Jesusislove 26]

Hi, I was just approved. Tricare does not go by BMI. You must be at least 100lbs overweight (acccording to the metropolitan life charts) with 2 co-mordbidities or you must be 200% overweight. If you are 200% of your weight you do not have to have any co-mordbities.

Edited April 2, 2008 by LLPlady3

[gina s. 0]

Everything I have seen so far just says one comorbidity......

[Jesusislove 26]

Gina, did you say you did not meet the wieght requirement? You seem like you meet the weight requirement according to what you posted above. Just trying to get an understanding. If you are not a 100lbs overweight they probably will not approve it. Even if you have one comorbidity and you do not meet the weight requirement, there is a great possibility you will not be approved.

[gina s. 0]

I'm 5'7'' and weigh 240-245. I know that I'm a hundred pounds over what I want to weigh, but I'm not sure what the "ideal" weight for me is.

[bama_belle 0]

I have Tricare Prime (just got it) and got approved for my first consult visit, which is on Monday with Dr. Stahl. I'm so excited, especially since I argued with United Health Care for over a year to get approved. I'm well over the 100 pd overweight mark with a BMI of about 50, have diabetes, sleep apnea and fibromyalgia along with bursitis in my sholders and hips. I think I'd just kill over if they said no. I am so hoping this goes quicker now that Tricare has given me this green light.

[minpinmom 2]

Here is a Chart by Met Life:

Met life ideal height weight tables references

I know you have to meet the requirements on the high end, so at 5'7", your ideal weight for a SMALL Frame is 123-136lbs. So 100 lbs over 136 would be 236 and 200% over 136 lbs = 272lbs

So, if you have any co-morbidities, you can get in on the 100lbs over with co-morbidities. If no co-morbidities, start adding weights around your ankles when you weigh :-)