Tricare Approval?

[JamieNP 20]

Has anyone been approved by Tricare with being less than 100 lbs overweight?

I am about 85-90 lbs overweight with sleep Apnea and High blood pressure (therefore I have my 2 comorbitities).

Before I get started, I want to know if there is even a chance of getting approved.

Thanks!!

[eazes 0]

Tricare may approve you because of the 2 comorbities but that's not always a guarantee. From what I have seen with various doctors that Tricare referred me to over the years. They will probably approve you to see that doc but it is up to the doc to say yeah or nay when it comes to the surgery. IMPO, I think you will be approved. Let me know how things go.

Good Luck!

[Jesusislove 26]

Hi, being under may not be approved; however, I would still give it a try.

[aculberg 0]

Hi there - I am kinda going through the same thing...I'm about 10 lbs under the magic 100 lbs...I have read some things on here about wearing lots of layers of clothes when you weigh in and someone even mentioned ankle weights...kinda scary, but if it works! Its so sad that we have to already *have* problems, i.e. the co-morbids, instead of getting the surgery to be pro-active...sigh! But I am taking the risk and have my initial consult with the surgeons office next week...and just hope and pray that I get approved!! Any other info anyone can give would be great, even some examples of some people that did get approved under the 100 lbs just to have some references and some hope! lol

[JamieNP 20]

I went to the seminar and found out some information. Tricare only has the weight requirements and the MD referral. The surgeon that I chose only requires a gallbladder scan. So I do not need the psy eval, the history of weight loss attempts, etc. He said all of this extra stuff is so insurance companies can come up with some reason not to pay.

Now I just have to make an appointment with my family doctor to get the referral. I don't know what Ht/wt chart is used in this decision, but according to some, I am 10 pounds under (this is naked and on my bathroom scales). My dr's office scales always weight heavier. Wish me luck!

[IntoLess 0]

MetLife scale is used by Tricare Met life ideal height weight tables references

Unless otherwise specified by doctor, evertone is medium framed by default for Tricare. And you must have one comorbid for Tricare as well, like high blood pressure, arthritis of the weight bearing joints, etc.

From Tricare.mil

"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"

[JamieNP 20]

I just hope my surgeon says I am small framed...

Oh, and one more thing, does Tricare do the figuring, or does your Surgeon...as far as how much over weight you are. For instance, according to the table, I am supposed to weigh 120 lbs (on the low end). Will they use that low end figure?

Edited June 22, 2008 by JWRN

[JamieNP 20]

Ok, my pcm is sending the referral now. I have an appointment with the surgeon on July 11 (they are closed next week). Now, if my insurance will pay for it..cross your fingers!

[mom2twins 0]

my pcm weighs me with my shoes on. If you are realy that close a few extra milshakes would probably get you the approval, if you want to go that far. I know we all hate the thought of gaining more, but if it is just for a short time to get the approval it might be worth it not to be turned down.

[JamieNP 20]

Yeah, I thought about putting a few extra heavy things in my pockets! I didn't even have to meet with my pcm...the office is writing the referral now. woo hoo!! With clothes on I am about 5 lbs under the low weight/small boned..with 2 comorbidities

[AZArmyWife36 0]

Yeah, I thought about putting a few extra heavy things in my pockets! I didn't even have to meet with my pcm...the office is writing the referral now. woo hoo!! With clothes on I am about 5 lbs under the low weight/small boned..with 2 comorbidities

Hi! I as well have Tricare and do not meet the 100lbs overweight. I have a sleep study scheduled this weekend and after that it'll be submitted to Tricare. I'm hoping I'll be approved. I was curious about the sleep study. Any information is greatly appreciated. Thanks!

[aculberg 0]

Sounds like were all kinda in the same boat, as far as the weight part goes. I have my initial appt with the surgeon on Wed...wish me luck!! lol I too am interested in the sleep study, how does that work??

[IntoLess 0]

Okay, I was just approved, so maybe this will help a little. First off, your surgeon will know what to say to get you approved. They will not lie, or stretch the truth, they are just as scared of insurance fraud as the rest of us, if not more.

I weigh 225 and am 5'2", according to my surgeon. I am actually closer to 5'4", depending on the day I am anywhere between 5'2" and 5'4" (chiropractor does a good job of realigning my lower back). They asked, and did not measure and I am unsure of my height that day, but they did weigh me fully clothed, which is procedure. The MetLife scale says fully clothed if you read the fine print. These two inches didn't give me a lot according to the scale, but put me over for the "small frame" category and in the middle of the "medium frame" category. If you read the Tricare handbook it says "100 lbs over for height and bone structure with one comorbid". I do not know how they submit it, as far as wording, what is included in the paperwork, etc, but I made sure to point that out. My first appointment my surgeon looked at my height and determined I should weigh 120 (high end of small frame on scale). When I went in for my second appointment I made sure they had copies of my diagnoses for high blood pressure, arthritis, and degenerative disc disease to submit with my letter of medical necessity.

SO, long story short, I made sure the office knew what the insurance was looking for, as they do not do a lot of Tricare patients, some, not many, because most people around here prefer to drive a shorter distance, and who can blame them. I was just tired of driving to the town where my other choice was located. Go online and print out the page for the gastric bypass/lap band surgery information on Tricare.mil, or go to your local TSC and get a copy of the handbook to show your surgeon's insurance people, and let them know what key words they are looking for. Again, they WILL NOT lie to get you approved, but they will do what is necessary to get you approved. And it still ended up being a long story.

Moral of the story, trust your surgeon's office, they do this daily. Ask if they need any insurance info if they don't deal with Tricare often.

[JamieNP 20]

You will go to the hospital's sleep study clinic about 9 pm. They will hook you up to EKG monitors, O2 saturation monitors, EEG monitors and then they will watch you sleep. Call your physician that ordered it if you can get some Ambien to take before you go, as I was not able to sleep well my first night. You will also wear a monitor around your nose and mouth to measure how bad you snore. When you wake up in the morning you will want to take a shower, as all of the EEG monitor leads are basically "glued" to your scalp. Then you leave. The results take about a week. If you have sleep issues, you will return for another study, with a CPAP or BiPAP machine. They will basically do the same kind of monitoring, but will tweak the machine while you sleep (by remote control) so that you have enough positive airway pressure to keep your airway open. Personally, I have never slept better. The mask (I use the nose mask) can be uncomfortable and takes awhile to get used to, but I have yet to sleep with out it.

Good luck!

[aculberg 0]

Thats great information, thank you so much! So now I know to make copies of the insurance requirements and copies of all the diagnosis' to show the insurance specialist.