Tricare Approval or Denial??

[Ready4a2ndChance 0]

I believe there is just a general chart that they use that goes by your height............I **should** be between 124-138, for my frame and height. I believe they look at bone frame too..........here is a chart at Height and Weight Chart - Women, Men, and Teens ? Height / Weight Tables ? Recommended Weight for Males and Females. This should give you a GENERAL idea. I'm 262 so I know at 5ft4 without a doubt i'm 100lbs over......lol. No question for me..........Have you talked to your doctor yet??? Is this something you are researching????

[haroldrussi 0]

My wife and I were both approved the first time thru. I am scheduled for 4 March 09 and she talked it over with the Dr. and they changed her's to a bypass because of better b/p control and the higher weight losing possibility. She is now scheduled for 6 April 09 for the bypass and that was harder to get approved thru TRICARE for some reason. They balked at first but when I webmailed them about the change they finially got the information correct and she is now approved. Just poor information exchange is what I figure the problem was. She is now approved for any WLS shown by TRICARE.

[lisw55 0]

I believe there is just a general chart that they use that goes by your height............I **should** be between 124-138, for my frame and height. I believe they look at bone frame too..........here is a chart at Height and Weight Chart - Women, Men, and Teens ? Height / Weight Tables ? Recommended Weight for Males and Females. This should give you a GENERAL idea. I'm 262 so I know at 5ft4 without a doubt i'm 100lbs over......lol. No question for me..........Have you talked to your doctor yet??? Is this something you are researching????

I should be in the 136-150 range, so at 248 it is a close call. I have been working on this since last August. My PCM and surgeon are ready to go, but my primary insurance decided to exclude 35+ with comorbilities as of 1 Jan 09. I faxed my appeal to UHC yesterday, which I believe will be denied so am thinking plan B is Tricare or plan C to change to another company in Nov during Open Season. It's so hard for me to believe that my employer (US Army) would exclude wls when they are generally very supportive of the health and wellness of thier civilian workforce. I promised myself there would be no more whining, so I better get a grip and think positively!! Thanks for the direction with the chart.

[Ready4a2ndChance 0]

well keep us posted on how things go with you..........i wish you the best of luck. I know that personally for me, I feel like this is my only hope at help since nothing else I seem to be doing is working.............i'll keep my fingers crossed for you:cool2:

[Ready4a2ndChance 0]

Well I got the call from the bariatric appointment lady at the surgeons office.............They have classes every other tuesday...SOOOOOO...........They pick 7people and we are seen individually then we go to a class together. She did a phone screening with me to see if I qualify, and I do. Problem is they dont' have anything available til the end of MAY!!! Then she said it could take up to 4months........i was really hoping for a sooner procedure but I guess I should be happy that i am getting it..........My hubs is going to Afghanistan in March and i wanted to lose some before he got home and suprise him with my new bod, LOL. Oh well...........

[mrsmajpaul 0]

Hello all. New to this whole thing. Hopefully someone out there will be able to shed some light on this process. I went to my PCM at a MTF the beginning of Feb 09 to get a referral for lapband surgery. About 2 1/2 wks later I received approval from Tricare Prime to see a specialist. I attended his seminar. I have an appointment to see him on April 1st. I guess my whole confussion is that when trying to get the approval every time I spoke with tricare they kept referring to my referral as " a request for general surgery". I know the specialist has to make the call if I am cleared for surgery...but do you think it has already been "blessed" by tricare if they are willing to send me to a specialist? I have been on Weight Watchers since Nov...not too much success there...I already had my psych eval at a MTF. What do you all think? Thanks so much Caroline in VA.

[haroldrussi 0]

I was not approved until TRICARE put the approval in the system which stated approved for lapband. So far it appears from what you have stated is that you are approved for consultation with the WLS. TRICARE in my case approved me at 120lbs over my recommended weight but I have read on this site they disapprove people that are only 99lbs over their recommended weight so If you are close either cheat(add weight to clothes) or gain so you are at least 100lbs over (I didn't really say to cheat the insurance did I???) but be aware they look that close but go on the recommendation of the WLS. My wife and I started the process on Dec 3, 08 and I got my band on 4 March 09. She changed her mind and is getting the bypass on 6 April 09. I was completed first because I am a chicken and might have backed out if she had too much pain. Other than the port site pain I am doing great. and I am told the port site pain is normal as long as it does not turn hot and red. Good luck on your approval with TRICARE but I think you can get it approved, If denied keep trying....

[mrsmajpaul 0]

thanks....I am at a BMI of 36 with 2 co-morbids (sleep apnea and high bp) with a severe family history of heart disease and diabetes....and sometimes I think I might be pre-diabetic. My mom at 66 just had a quad-bypass before christmas and is doing great.

[munger 0]

Hello all. New to this whole thing. Hopefully someone out there will be able to shed some light on this process. I went to my PCM at a MTF the beginning of Feb 09 to get a referral for lapband surgery. About 2 1/2 wks later I received approval from Tricare Prime to see a specialist. I attended his seminar. I have an appointment to see him on April 1st. I guess my whole confussion is that when trying to get the approval every time I spoke with tricare they kept referring to my referral as " a request for general surgery". I know the specialist has to make the call if I am cleared for surgery...but do you think it has already been "blessed" by tricare if they are willing to send me to a specialist? I have been on Weight Watchers since Nov...not too much success there...I already had my psych eval at a MTF. What do you all think? Thanks so much Caroline in VA.

Well you have step one done! You get to see the specialist. You now need them to say that you are at least 100 pounds over weigh, have one co-morb (high blood pressure, diebetic...) and have a body/bone structure that truly means you are over weight!

I got to see the speciallist - in July.

He sent in the paper work that said I was 100 pounds over weight and had high blood pressure, high cholestral and lower back problems.

He forgot to mention that I was 5'8" and had a medium body frame so I was denied!

EVERYTHING MUST BE ACCORDING TO THE REGULATION!!! If not they will make you appeal - the appeals take longer than the regular visit.

Hope this helps,

Mel

[*barbara* 0]

Hello everyone!

I just started this process. I live in new england and have insurance with Martins Point, which is part of US Family Healthcare, and then that is through Tricare...so confusing.

Well according to the Met Life table I should be 124-138 lbs, but life has played a cruel joke on me and I am 250lbs!

I found Tricare's policy manual about WLS and am kinda confused. My question is...Do I absolutely need to have associated medical condition (diabetes, arthritis, sleep disorder, etc.) in order to qualify?

I really don't have any other issues other than just being fat. I have had issues with my thryoid since I was 16 years old and just last month I had the darn thing removed because I had a cancerous nodule. So I am hypothyroid...and my mom is diabetic...so I have the risk of becoming diabetic.

All I know is if I continue on the track that I am I will continue to gain weight and in the end develope a co-morbity.

Edited March 25, 2009 by *barbara*

[Amy Stew 0]

I am just now starting my journey. I went to a seminar with my neighbor kinda just looking into it and it was so eye opening to me.

I am 4''10' and 210lbs. right now. My BMI is 44 as of right now. I am 22 and will be 23 in June. For Tricare the nurse at the surgical center said I would need to be 218 to be approved with out co-morbids. Since they don't go by BMI, but by weight. My ideal is 110lbs. for height. I have had moderately high blood pressure, but no meds, asthma, and I did have thyroid itis for 5 months a few yrs ago that made me gaint 50 lbs. I have tried everything my Dr. has told me to do. I went to the HAWC had an exercise program...everything. My family has a history of extreme obesity, high bp, cholesterol.

I am going to gain back the 5 lbs i just lost and go for it. I am young and I do not enjoy life because of my weight. I am in pain at night if I go out and have a nice day outside and I just don't see myself loosing this weight because my parent never have. They say since I have the insurance I should definitely get the lap band done, so that I can better myself health wise and have a brighter future.

Do you all think I will be approved?

[teambrooks2 0]

I just recieved my second denial. They waited the whole 59 our of 60 days to deny my appeal. Does anyone know if you can appeal more than once? I am 218lbs. 5'3 and have hyperthyroid and hyperlidmia.

They say I do not meet the 100lb requirement. Any tips hints or ideas for dealing with this total frustration? :laugh::thumbup:

[connie45331 0]

Has anyone got approved from tricare for the band being under 100lbs overweight? I am 86 lbs overweight, with family problems of heart, also bad back pain, I just went through a procedure friday to check me for gerd. My bmi is 41.6. I am just waiting on the final approved for the surgery from tricare. I know that one of there requirements are at least 100lbs overweight...Anyone got approved without being 100lbs overweight???

:thumbup:

[KarinaM 0]

I just recieved my second denial. They waited the whole 59 our of 60 days to deny my appeal. Does anyone know if you can appeal more than once? I am 218lbs. 5'3 and have hyperthyroid and hyperlidmia.

They say I do not meet the 100lb requirement. Any tips hints or ideas for dealing with this total frustration? :biggrin:

I was desaprovedby Triwest and they also took their time (55 days). I deceded to go my last appeal (to the Dept of Defense contractor). They were very nice. (you need to get your weight up, get some "extra weight if you know what I mean). It took 2 weeks for me to get approved. DO NOT GIVE UP!!!!

[lisw55 0]

I just recieved my second denial. They waited the whole 59 our of 60 days to deny my appeal. Does anyone know if you can appeal more than once? I am 218lbs. 5'3 and have hyperthyroid and hyperlidmia.

They say I do not meet the 100lb requirement. Any tips hints or ideas for dealing with this total frustration? :ohmy::thumbup:

Hello, With a BMI of 38.6/218, you only need to gain 12-15 pounds. If you are set to have the LB that is the easiest and fastest way to solve your problem. Have you been tested for sleep apnea? If not have your PCM refer you for testing. Just my 2 cents. Try not to be so frustrated by the insensitivity of Tricare, but at the same time you may need to go above and beyond what others have had to do to get the approval. This is based on myown personal experience. Take care and bee good to yourself.