Question:
I am seeking Tricare patients with the same BMI or lower and no comorbidites
I am now gearing up to possibly fight a denial and this site has been so helpful so far. I need to find Tricare patients with a BMI of 42 or lower with no comorbidities that are listed in Tricare's handbook. These are diabetes mellitus,hypertension,cholecystitis,narcolepsy,Pickwickian syndrome(and other severe respiratory disease),hypothalamic disorders and severe arthritis of the weight bearing joints.My authorization is being held up because although I am 100% over my ideal body weight my co morbidites are not in this list. I have GERD, high cholesterol, migraines and joint pain associated with the obesity(per PCM's referal letter). Thank you in advance for all your help. I am looking to print this all out to be sent along with my appeal if it comes to that if not I will add it to my history of dealings with Tricare and WPA. Thank you again. — S C. (posted on June 6, 2003)
June 6, 2003
Hello. I'm a Tricare Prime person... well thats my coverage anyway. Had my
lap RNY in February. I just wanted to let you know that with GERD and
joint pain you should be fine with the co-morbs... the high cholesterol and
migraines will add to your cause. I had very similar co-morbs and was
about 130# over ideal weight. I was approved on the first letter with no
questions. My BMI was higher than 42 - but not by much.
— Anne R.
June 6, 2003
I know someone who has tricare whose BMI was just at 40 or just below...
She had no comorbs and she was approved through tricare with in weeks.. HTH
— Catherine B
June 7, 2003
Hi. I also have Tricare Prime. BMI was 43, no co-morbids and I was
approved on the same day. The whole process from PCP referral to surgery
date took less than 30 days. I had GERD and joint pain, but my family
history includes stroke, cancers (some of which are worse in the obese),
heart attacks and a sad host of obesity related deaths. Keep fighting.
Good luck to you.
— TraciB
June 7, 2003
I am 9 weeks post-op LAP RNY.I have tricare prime and did not have one bit
of trouble with them. To start with, I only dealth with the local Tricare
office. I did not have my paperwork sent to the regional office like most
do. I was told if the surgeon completed all the criteria, that the nurses
at the local office could give the authorization. I was also very nice to
the ladies, respectful. I think that goes along way. I had a BMI of 40 with
NO comorbs listed in the hand book. I also had GERD and joint pain (not
arthiritis). I made sure the surgeon stressed how this weight was affecting
my quality of life as a nurse, mother, and wife. I was approved and had a
surgery date within a few hours of the Tricare office getting the
paperwork. I only called them once a week and always spoke the same person,
again being very nice and making them feel like they were doing me a huge
favor- thanking them alot for their time and effort. Because in all
actuality- they were the one who were diecided my future. Feel free to
email me if you have any more questions.
— Jan S.
June 7, 2003
I am not 200% over my ideal body weight. By the metropolitan weight charts
my ideal body weight should be 125. 200% of that would be 250 when I went
on for my inital consult I was 236.7 I was hoping to qualify just from
being 100% over my ideal body weight with GERD, high cholesterol, joint
pain, migraines and family history. I was told this past week that my
authorization was being held up because I do not specifically meet
Tricare's requirements. I am getting prepared now for the appeal process
and feel that if I can show where other people who were less qualified or
with the same qaulifications as I have were aproved for this surgery I will
have a better chance to get approved through an appeal. My surgeon's office
has never dealt with and appeal process and the people here at my Tricare
service center have been less than helpful with the whole surgery process
all together so I can't count on them to help me at all with the appeal(if
it comes to that) Thank you all for the responses anyway, I had read most
of your profiles previously and had great encouragement that my story would
be similar to yours but it hasn't been.
— S C.
Click Here to Return