Tricare weight requirements

[Lindalew 0]

Hi everyone,

I have been unsuccessfully trying to find someone at Tricare that could answer a few questions for me about qualifying for lap band surgery. I was wondering if anyone has had any luck with getting their surgery approved if you don't quite make the 100lbs overweight part. I am 5'5" and weigh around 223 but also take medication for high blood pressure, high cholesterol and insulin resistence. I've tried to look at weight charts but there are so many different ones out there I can't figure out if for my height I make the 100lb requirement. What a hoot...for once in my life I'm worried that I'm not fat enough. If anyone can help me with this is would be much appreciated. I've got an appt with the Dr's office Oct 13 but if there is no way Tricare will pay for the surgery I will probably put it off for awhile.

Thanks!

Linda

[RestlessMonkey 7]

Tricare should provide you with their standards. I am not sure but believe that, if you aren't at least 100 over, they won't cover you. What is your BMI? That also has to be high.

[Lindalew 0]

Hi RestlessMonkey,

Thanks so much for answering me so fast. I just did my BMI and it is 37.1. The weight loss clinic that I have an appt with wants $150.00 for the initial appt. I just don't want to spend the money if there is a really good chance that I wouldn't qualify under Tricare. I am hoping that maybe someone else has been in my position and have had some luck. Thanks again.

Linda

[lsullivan68 0]

I believe it all has to do with your doctor and how they write things up. I went on a Thursday to my doctor and received approval from Tricare by the following Friday. Scheduled my surgery date that Friday and had my surgery done within 3 weeks of getting approved. Tricare paid 100% of my surgery and I couldn't have been happier with the results? P.M me is you want more specifics. Good luck!

[mcrowder 0]

I didnt have any trouble having Tricare covering mine. I did have a high BMI, but there is a seperate criteria if you have high blood pressure and or diabeties. Which I have both of them. I had mine done in Aug and they paid for everything. I had mine done at UNC Chapel Hill and they were wonderful.

[RestlessMonkey 7]

Lindalew: I too used tricare but at 405 pounds, I didn't need a comorbidity to get approval. I've read on the boards that unless you have TWO comorbidities, or a BMI OVER 40, tricare will deny you. You can enter "tricare" in the search bar and get lots of info...

I believe that your hypertension is a comorbidity, but I don't think high cholesterol or insulin resistance are.

If you want the surgery, call tricare and have them send you the requirements IN WRITING .... or tell you where on line a persistent link is to the data. Armed with that, you can decide. But at 5'5" (my height, by the way) 223 isn't considered 100 over. You'd need to be closer to 240-250 (but again I don't know exactly...I'm just remembering stuff I read, it didn't apply to me so I may be misremembering)

I'd suggest 1. find a clinic that doesn't charge for a seminar and accepts Tricare. Attend, and then ask them if they provide help filing the claim. My clinic has an insurance person who knows what every local coverage requires and files for us. They didn't charge me for that. AND while waiting for that seminar, call tricare and get a copy of your coverage. (you can't go by what person on phone tells you; they are often incorrect, sadly)

I'd take those steps and then decide from there, once you have more info, both on the band, and on what tricare will or won't cover.

[mljalways 1]

What region are you in??? I hear that TriWest is harder to get approval. I submitted in the south region on Tuesday and have my fingers crossed!!

[lsullivan68 0]

I'm Tricare South and truly it was easy! Find someone that doesn't charge for the seminar & accepts Tricare and give it a shot! It can't hurt to try.

[JamieNP 20]

I am 5'5 and I got denied when I weighed 220.5. I had to gain 6.5 lbs to be approved, so my denial ended up getting reversed and I had surgery yesterday.

I also had 2 comorbidities.

[mljalways 1]

JWRN........... Congrats on surgery:) How are you feeling?

[mljalways 1]

Just got word that TRicare denied my consult with Nutritionist. Anyone else have this issue??? No word on the surgery yet.

[tomatogirl 0]

Just got word that TRicare denied my consult with Nutritionist. Anyone else have this issue??? No word on the surgery yet.

I went through my MTF to get an appt with the nutritionist. I got my PCM to put in the referral.

[Lindalew 0]

Thanks so much to all of you who took the time to answer my questions. I called Triwest again today and finally got someone who could answer a few questions. I am in the Kansas City area and I also called the weight loss clinic and asked them if I could get my $150.00 back if I didn't qualify for the surgery with Tricare. They said no problem, but I think I will still get that in writing before my appt. My husband is retired Air Force and is still working so Tricare is our secondary insurance. The woman I talked to today said I would first have to get the denial from BC/BS and then send in the claim to Tricare. HOLY COW, this sure does seem like a complicated process! The weight loss clinic said they will do all the paperwork for me so I guess it can't hurt. Now all I have to do is worry about gaining a few more pounds before my appt so I can make the 100lb requirements. That shouldn't be too hard!! Thanks again for all your help.

[phillyfawn 0]

I have Tricare Prime and go to a MTF (West Point), and I recently started the path to surgery. I had no trouble getting the surgical referral (I just asked for it), and the surgeon signed off three days later. Now I am on my way down the checklist and am planning on having surgery at the end of this month.

I am only 90 lbs overweight (by their Metlife standards), but because I am short my BMI is 38. I think it needs to be one or the other. Also, I had apnea that wasn't corrected by surgery, so I think that helped. When you go through an MTF there is no seperate Tricare approval needed and it is at the sugeons discretion.

Hope this was helpful!

[KarinaM 0]

Just got word that TRicare denied my consult with Nutritionist. Anyone else have this issue??? No word on the surgery yet.

Hi, I had to pay for my nutricionist because TriWest will NOT pay for it. I agree that TriWest its harder to get proved.