Tricare

[aculberg 0]

RestlessMonkey, How did your surgery go? Congrats on finally getting banded!!

[RestlessMonkey 7]

THANK YOU! It went fine! I was in by 730 and out by 9...it took forever to go home, however, because I had to wait on X-ray to have a swallow test (I was all for taking the test, just wanted it to happen faster!) and I was home by 2pm. I'm a little more sore than the first time, but I'm sure that's due to 1. having the BAND! LOL and 2. having my surgical sites re-opened before they'd totally healed. I'm doing good though; no nausea at all ever, able to keep Water down, hungry (which I think is a good sign of healing) but hanging in like I'm supposed to. I am so happy this has happened! I know it will change my life for the better. Thanks for asking about me!

[Maggies 0]

:wink_smile:Just got back from having my Upper GI done. I thought that was the last test they wanted, but because of my age they want a Cardiolite Scan which I have scheduled for this Friday. Then it should be submitted to Tricare for APPROVAL. I have had more tests done since I started this than I have had in all my life. But better knowing if there is a problem than not. Wish me luck on a speedy approval and safe surgery. Maggie

[sunnylilme 0]

I'm so upset. I just got denied from Tricare.

My doc submitted the paperwork on the Aug 28th, and I just saw online today I am denied.

I am 100 lbs overweight.

I have moderate sleep apnea, which I think is a comorbidity.

I just don't know what went wrong.

Tricare says wait for my denial letter for info on how to appeal..

[mljalways 1]

I am tricare too.........hope it doesnt take that long

[mljalways 1]

I am sorry to hear that sunny.........where do you go online to check?

[rodriguezequal 3]

TriCare uses different measurement scales than most insuarance. Some people got denied by tricare because they were 6'5 pounds under what they're supposed to be to get the lapband...good luck and I'm so sorry.

[JamieNP 20]

I was the one that was 6.5 lbs under the requirement. I gained some weight, went back in to reweigh, and had gained the 6.5 and more. According to my denial letter, they go by the Met life ht/wt chart and from the number that they gave me, it was the lowest number in the Medium build chart. I have 2 comorbidities (HTN and Obstructive sleep abnea with cpap) and tricare acknowledged this. If you meet the requirements and they deny you, then you need to talk with them and appeal.

BTW, my surgeons office resubmitted the new wt on Friday afternoon and I found out Wed (Monday was a holiday). So they were pretty quick. Good luck!!

[Maggies 0]

:thumbup:JWRN, Congratulations for your approval. Sept 30, isn't that long off. Do you have to do a pre op diet? I hope to find out this week if I'm approved.

Maggie:shades_smile:

[sunnylilme 0]

https://infocenter.humana-military.com/south/Bene/obs/InfoCenter.asp

[sunnylilme 0]

Okay...I am 5'6 253. I got denied.

I had my sleep test, and I have moderate sleep apnea, and they want me to go back for a cpap to get fitted for the sleep mask thingie.

Is sleep apnea a comorbidity.

Is it 100 lbs over ideal weight with 1 comorbidity?

I am so, so upset.

I'm worried I'll be this huge for the rest of my life:(

[Maggies 0]

sunnylilme, Sorry to hear about your denial. APPEAL!!!! Now I'm really worried about getting an approval. Our weight and height is to close for comfort. :shades_smile: I also have sleep apnea. Will let you know when I find out. It should be sent to Tricare this coming week. Maggie:cool2:

[JamieNP 20]

Sunnylime,

sleep apnea is a major comorbidity. When those results come back they need to be sent to Tricare. Did you have a psy eval? Tricare had initially held mine because they didn't have a copy of my psy eval.

According to my surgeon, Tricare needs a psy eval, EKG and labs, upper GI.

What does your denial letter say. It should give you a detailed reason for your denial.

My preop is starting today. It is supposed to be a month of lowfat, lowcal liquid diet. I am going to do a "mostly liquid" diet but my parents are cooking me a big steak dinner this weekend, and my friends and I are going to our favorite restaurant and having margaritas before my surgery.

[sunnylilme 0]

My doc doesn't seem to know ANYTHING about Tricare. He's only ever had one Tricare patient before.

I asked him if I qualified, or if I needed a co-morbidity, he said he didn't know. He would hold my paperwork until I wanted them to submit.

I think maybe Tricare didn't get my sleep apnea info fast enough, or maybe I have to have my second sleep study with the cpap before I have that particular co-morbidity?

The doc hasn't asked me to get a psych eval, I figured I had to do that after I got approved.

I thought I was going to be a Sept Samuri. I've been having dreams at night about the new me:((

[JamieNP 20]

Don't get discouraged. If you need a psy eval, you can set up your own. You may have to do the leg work here. Let me give you some codes...make sure they use these. You are going to have to have proof of some type of comorbidity...get a copy of the pulmonologist letter.

From Tricare Handbook

I. CPT1 PROCEDURE CODES

43644, 43770 - 43774, 43842, 43846, 43848, 43886 - 43888, S2083

II. DESCRIPTION

Morbid obesity means the body weight is 100 pounds over ideal weight for height and

bone structure, according to the most current Metropolitan Life Table, and such weight is in

association with severe medical conditions known to have higher mortality rates in

association with morbid obesity; or, the body weight is 200% or more of ideal weight for

height and bone structure.

III. POLICY

A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded

gastroplasty is covered when one of the following conditions is met:

1. The patient is 100 pounds over the ideal weight for height and bone structure and

has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis,

narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic

disorders and severe arthritis of the weight-bearing joints.

2. The patient is 200% or more of the ideal weight for height and bone structure. An

associated medical condition is not required for this category.

3. The patient has had an intestinal bypass or other surgery for obesity and, because

of complications, requires a second surgery (a takedown).

B. In determining the ideal body weight for morbid obesity using the Metropolitan Life

Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the

weight range. Payment will be allowed when beneficiaries meet all requirements for morbid

obesity surgery including the ideal weight within the newly determined range