need help..again..tricare...PCM

[chantel03 0]

okay, so this is mainly for those who have tricare....(although all help is appreciated)

so i went in today to see my PCM. ive been going thru the process since march.ive seen the nutritionist and had a psych eval.a month ago he told me i had to lose between 10-15 pounds. well i lost 13!!! i was so happy. i went in to see him expecting to get a referral to a surgeon, but instead hes putting all the paperwork directly into tricare. the only thing stalliing him is that my husbands deros isnt a year from the surgical date. but how can it be when i have no clue when the surgical date is?

i guess my question is, has anyone else just skipped all the blood work and surgeon and went directly to tricare? im also worried because now im only 87 pounds over weight. i told him if i lost any weight i wouldnt meet the 100 pound requirement.and when i asked him if if he was going to use my before weight he said no "we'll take our chances" grrrr. he's got nothing to lose. im the one doing all the work. im not too worried about the weight issue. if i have to gain it back i will. but seriously, no blood test or anything?!?!?

i have tricare overseas if that makes a diffrence.

Edited June 30, 2009 by chantel03

[beltranklan 0]

I am overseas also in Germany. My PCP also tried to just go to TriCare, but TriCare came back and said that the surgeon HAS to approve to do the surgery, so you will have to get the referral to the surgeon no matter what your PCP says. Anyway, the Surgeon said yes that day and faxed the information to TriCare right then. I had an approval within 3 days and my surgery was 2 weeks later. As for the Deros Date, they won't do your surgery unless you will be here for at least 1 yr after in case of complications. I never had any blood work done, no psych evaluation, nothing.

[chantel03 0]

thanks beltranklan.

i keep trying to tell my PCM that, but he refuses to do anything my way. he made me lose 13 pounds for nothing.its not even a requirement. and we dont mind extending our deros but how will we know the surgery date if my PCM wont let me see a surgeon first. i dont know what to do now. he cant even remember the type of surgery i want. he keeps telling me about the bypass.lol

i guess i'll go to the tricare office.

[beltranklan 0]

If I were you I would to directly to the TriCare office. I would go in person rather than try to call. Explain to them what is going on and see if they will write something up for you to give to the Doctor. If that fails, I have the email address for the TriCare Overseas Headquarters here in Germany. She approved my surgery herself the same day she got the paperwork. Possibly if you contact her and explain the problems that your provider is giving you she might be able to do something about it.

Another thing that I noticed when I was trying to get my local clinic to give me a referral is that they seem not want to help people get this type of surgery approved. They told me 3 times that they would not put in a referral for me to see anyone. They went so far as to tell me that TriCare STOPPED even approving gastric bypass and LapBand. At that point I went to the Tricare office in my clinic and got the regional information and faxed them my medical records. Once that happend it was a piece of cake getting it all done.

[chantel03 0]

If I were you I would to directly to the TriCare office. I would go in person rather than try to call. Explain to them what is going on and see if they will write something up for you to give to the Doctor. If that fails, I have the email address for the TriCare Overseas Headquarters here in Germany. She approved my surgery herself the same day she got the paperwork. Possibly if you contact her and explain the problems that your provider is giving you she might be able to do something about it.

Another thing that I noticed when I was trying to get my local clinic to give me a referral is that they seem not want to help people get this type of surgery approved. They told me 3 times that they would not put in a referral for me to see anyone. They went so far as to tell me that TriCare STOPPED even approving gastric bypass and LapBand. At that point I went to the Tricare office in my clinic and got the regional information and faxed them my medical records. Once that happend it was a piece of cake getting it all done.

thanks for the advice. and i might end up asking for that number sometime in the near future. i talked with my husbands first shirt today and shes taking the matter into her own hands. she's really upset that the doctor made me lose weight just to disqualify me for the tricare requirements.

she's calling the clinic tomorrow to get the ball rolling. my husbands deploying in august so she said shes gonna put a rush on it. hopefully shes telling the truth. we'll see.

[scottishlassywsp 0]

Good luck with all of this. I have Tricare also and I didn't need to lose/gain. I did have to have a psych consult which I didn't mind....it was nice to get a lot of stuff out!!!! :thumbup: I have had no problems (knock on wood) and my surgery is scheduled for July 13th.

I hope that you are able to get it all straightened out and get the surgery.

[katwmn63 0]

i would go so far as to issue a greivance to the military treatmet facility administration. "we'll take our chances" ??? I say BS! he has no right to take those chances on your behalf. Make sure inyour grievance (if you file one) you demand he use the weight prior to the 13 lb loss. going straight to tricare might help, but if you can somehow get them to approve even a consult with a surgeon then let the surgeon deal with tricare... that wold be a way to go as well. it's hard for an active duty member to cut out the pcm, but as a dependant..you might be able to swing it.

good luck and keep us posted!

[Lilpeach_059 0]

I have Tricare prime, but I didnt have to lose any weight. Tricare only wanted the info that the surgeon (varies by surgeon) deemed necessary like psyc eval, TSh level, pulm clearance and nutrition consult. Now that I am approved the surgeon can tell me to "jump thru hoops" before he will do the procedure.

But I hear you can go to a MTF w/o going thru so much because Tricare will automatically cover it.

[Tina254 0]

**Questions**

I called Triwest because I didn't know what "approved with modifications" meant and they told me that my first doctor appt for my consultation is approved and the reason they had “Modifications” on there is because I didn't chose my doctor yet. I did choose my doctor and made my appt, yay! Has anyone been denied after the first (approved) consultation with the surgeon? If yes, how and why?

I forgot to ask the lady I talked to on the phone from Triwest. Can I print out the approved status I got online and bring that to the doctor or do I have to wait for the letter in the mail?

Another thing I saw on my online status that I don't quite understand and I forgot to ask is about the other thing on there. There are two things with approved with modifications...

~"office consultation: Approved w/Modifications " &

~"office/outpatient visit, new: Approved w/Modifications"

So I know I'm approved for the consultation but what is "office/outpatient visit, new"?, it says I'm approved for it but I don't know what that’s for...I'm thinking it’s the next appt after the consultation but I don't know, just asking to see if anyone has had this on their status online or approval letters and if they might know the answer. It’s a holiday weekend because of the 4th so I won’t be able to call until Monday so that’s why I’m asking you guys

Thanks for all the answers on my questions really appreciate it!!!

[Lilpeach_059 0]

From my experience with Tricare Prime is that they will approve the referral for an office visit as long as its a covered service (ie, gyno visit, endo visit, cardio visit) & they will deny those not covered (off base nutritionist, or psyc).

For them to approve a lap band surgery....the surgeon has to submit a packet saying the surgery is medically necessary & if the Nurse at Tricare agrees (& u meet the requirements on Tricare's website)...they will approve it.

To answer your question....unfortunately one can still be denied for surgery even after having approved visits to surgeon. But they really have to approve your visits to the surgeon to see if you qualify for the surgery.

[Lilpeach_059 0]

& Tricare approves everyone for an initial consult & then usually about 4 office visits.

& no you don't have to print out the approved office visits & consultation unless u want. The surgeons office should have a copy.

[Tina254 0]

Thanks so much lilpeach, that really helped me a lot!

I have another question for you (or for anyone who knows the answer), How is the 200% body fat calculated?

I'm 5'5 and 275lbs am I considered 200% over my body weight. According to the charts I'm suppose to be 127-141lbs for my hieght (medium frame). I dont quite understand how to calculate it. Thanks.

[Lilpeach_059 0]

Maybe if you tell the surgeon that u have a small fram he will put that in the paperwork. but I hear that they usually use medium frame for everybody.

I'm 5'5 and 231lbs with no 'real' comorbities according to tricare's website...but my PCM wrote a letter and put my weight at 241 & that I suffered from recurrent abcess, asthma & joint pain.

Do you have any possible comorbities?

[Tina254 0]

Right now I only have secondary amenorrhea, possible pcos, and pre-diabetic(but I haven't been diagonos with it yet) but diabeties runs in my family.

Right now I'm counting on my weight getting me to the 200% or over range. I'm hoping it does. My BMI is 44.

Thanks for all your help.

[Lilpeach_059 0]

I think 200% over would make you 282....i think u could 'gain' that by the time u see ur surgeon.