Step one taken for PS

I went to my doctor to talk to them about a referral to a PS for a pannicolectomy (TT) and maybe even the girls done. My husband is retired military so the base doctor told me she would refer me but doesn't think TriCare will pay due to no rashes etc. I told her that I had heard that might if it was before December 31 of the year following surgery to remove excess skin so I would like a referral to at least give it a try. The doctor did some calls and told me she would give me a referral but it is up to the PS to write up their letter of explanation in a way that will get TriCare to pay. I told her I understood and I am now waiting for my referral to come. I know people with TriCare who have had the WLS surgery here in Arkansas so I was able to have a referal to a doctor that I knew could get it approved, but I don't know anyone who has had PS here in Arkansas to be able to know of a good PS doctor here. But atleast I took the first step and now to see what the PS says and to write everything up in such a way to that TriCare will approve. I'll keep you all posted as to how everything is progressing. It will be about 10 days before I have my referral for the consultation. Susan thanks for the info earlier. My husband laughed because he said it seemed like I knew more than the doctor and the active duty referral folks.

Good luck with that, Teresa. Let us know what happens. Lisa

WTG on taking that first step. I knew that it was exciting for me when I took it. I have my consult this Wednesday. I don't know if it will get approved or not, but I am excited to be taking that first step(or is the consult the second step? making the call was the first step) in getting PS. I hope you can find someone you know will do a good job and will be able to word the paperwork to get it approved. I am confident that the surgeon I chose is my "best chance" of getting mine approved. He is a doctor within my insurance company that works almost strictly with WLS patients. I am just very anxious about my appt and the approval process. URGH!!! Hopefully he will be able to put my mind at ease on Wednesday. Wishing you luck, Tabby

Hi Teresa!! Congrats on getting the referral. Okay, next step. Make SURE the PS submits for the panniculectomy and NOT a tummy tuck. The wording is super important. TriCare will pay for the "excess skin removal" but will not pay for a tummy tuck, which is a slightly different procedure. According to TriCare guidelines, they will do the pannis up to Dec 31 of the year following WLS, no problem. The "girls" are a different story. With them, you have to show "medical necessity". If you've been complaining and had it documented about back pain from the big boobs, marks on your shoulders from your bra working over time holding them up and/or rashes, you have a chance at getting a breast reduction. They don't call it a lift - even though that's basically what they will end up doing for you. Once they remove the excess skin and put the girls back up on your chest, you've basically had a breast lift. Again, it's all in the wording. If you'd had a rash or two, that really would've helped with the medical necessity. The key is to find a PS or even a general surgeon who takes TriCare to do the procedures. Most of the time, they know the guidelines well and know exactly what to say to get the approval. If you need any other pointers, just let me know. Question....have you talked with the HBA at the military facility there? They should be able to point you in the right direction of docs who can help with this. Of course, you may have an HBA like some I've known who don't even know how to get to the TriCare office much less what the manual says!! Let me know if there's anything else I can do to help you with your approval!!! Good luck!!! Susan

Susan, thanks, I did keep insisting with the doctor I talked to on base that it has to be a panniceloctomy to remove excess skin. I told them that it can't be called a TT or TriCare won't pay. The doctor told me just make sure I tell the PS that. From what I gathered talking to the doctor and the referral office I know more from what you told me than they do so I doubt they will be much help. I'll keep you posted on what happens after my initial consultation. I figure what is the most TriCare can say "NO", but it is better to have tried than to wonder if they would have.

It was my understanding that PS isn't really even condiered til you are at least 18 months from surgery. By that time you should have lost most of your weight and stabilized. I'd be interested to know how it goes.

Aime I will keep you posted. I have lost 90% of my weight because I only had 100 to loose to begin with (I barely qualified for the surgery). I am actually wearing a size 6. I can't wait til 18 months out because if I do then there is no possibility for my insurance to pay I have to have it done by December 31 of the year following my surgery if I have any hope of getting it approved so I am actually on a deadline. I figure right now the most my insurance can say is "NO", but I hope they don't.