TRICARE STANDARD PICKS & CHOOSES REQUIREMENTS?

According to TriCare, I do not qualify for TriCare Prime, so I have Standard. It has become my understandint that many military individuals have not had a problem getting approved by TriCare Prime or Standard....their PCM or surgeon took care of everything and it was a 'breeze'. Naturally, my surgeon submitted an authorization and it is still pending.....pending for the following: 6 month supervised diet Cardia/Pulmonary Eval Physc Eval Mood/Anxiety Disorder/Physcosis H-pylori Drug/Alcohol Screening Endocrinopathy etc.... I meet the 'standard' requirements outlined by TriCare, as being overwieght by 100 lbs and co-morbidity (high blood pressure, glucose level at 122 and rising, joint pain...cholesterol so high I'm surprised I haven't had a heart attack yet!) Talking to 'different' individuals in the Medical Mgt. dept., one said this was 'standard' requests for everyone, while another said it was case based on the individual.  The one person I spoke to quoted their revision of April 2006, saying that a 6 month diet must be within the current year.....you must have been obesed for over 5 years....blah...blah...blah! My husband retires the 1st of March '07....then we will go to Prime....and if I don't get approval, I'm sure the way that TriCare works, they would make me start all over again with a PCM! I've read much on the previous Insurance Board on here about TriCare and how 'easy' it was to get approved and even posted on another message board here on OH and it seems no one else has had this problem!  These requirements are NOT by my surgeon, so I do not understand....I even asked TriCare WHY am 'I' having to submit to all of these requirements and no one else? A drug/alcohol screening?  Come on!!  If I had a problem with THAT, I'm sure I wouldn't need bariatric surgery!! Is there ANYONE that can EXPLAIN this to me the difference?  TriCare Prime people 'breeze' through it, I just don't get it!~ Thanks in advance!~~ Jl

This is pretty standard for what they require for most insurance companies now. 6 month supervised diet Cardia/Pulmonary Eval Physc Eval Mood/Anxiety Disorder/Physcosis H-pylori Drug/Alcohol Screening Endocrinopathy Several friends I have go through Fort Gordon here in Ga and they are required all these testings too.  Usually as part of the drug screening/anxiety disorder that is covered under the phys eval. 

Thanks for the info Amy.  My dr. had put me on a 1200 diet in July, needless to say it hasn't worked........and I haven't been back for a follow-up since then due to my work schedule!  I will be following up with her on my next half day off. I suppose your friends at Ft Gordon have Prime insurance?  Also, TriCare stated a 'current' 6 month diet, but I read on this site by law within 2 years? I pretty much have everything except for the diet, cardiac and pulmonary. Thanks for the response, I appreciate it! Jl

I don't think they are as demanding about the supervised diet as many insurers are.  So they might be able to submit it without it, as long as you have some weigh ins in the last 6 months and a doctor stating you are on a diet, that would work.  The 1200 calorie diet would work as documentation, keep doing that while you are waiting, but make sure you are doing some weigh ins monthly.

Just a word to the wise....If they tell you a 6mos supervised diet and you do not go once a month to see the dr it will not count as a supervised diet. They will make you start all over.  I don't know why they are giving you a hard time, but I have heard that their policy has changed from a year ago. Good Luck MOM

Thank you Amy and Mom...... What is most irratating is that you do not know 'what' the requirements are until you submit for authorization.  I am 100 lbs overweight w/co-morbidity. I know others have gone through many diets as well and some doctor's just do NOT say 'you have to lose weight' and put you on a diet!  Some overweight people actually get offended.  I wasn't offended, but just embarassed because I KNOW I need to lose weight, but easier said than done!  My doctor gave me one of her notepads to write everything down. Also, last year I paid $400.00 to Thin & Healthy and was able to lose 15 lbs.....but gained that back, PLUS 30 pounds!  It seems no one understands that though we may be able to LOSE the weight, it doesn't STAY off and we gain it all back AND MORE!!  I sometimes I wonder if I never tried to diet, than maybe I wouldn't have continued to GAIN MORE WEIGHT??...How ironic it is! I wonder how an appeal would work in this case?  I've not heard from my surgeon's office of these requirements, as I called TriCare myself.   Thank you both so much for your responses, I really appreciate it! Jl

LLLE,  WHICH SUGERY ARE YOU TRYING TO GET APPROVED?  TRICARE USUALLY APPROVES RNY WITH NO PROBLEM IF YOU MEET REQUIREMENTS, REGARDLESS OF WHETHER YOU ARE PRIME OR STANDARD.  DUODENAL SWITCH & LAPBAND ARE ANOTHER STORY.  DOES YOUR DOCTOR HAVE HISTORY ON OTHER PATIENTS USING TRICARE?  PREVIOUS PATIENTS ARE A WEALTH OF INFORMATION & ADVICE.  I HAVE PRIME, AND HAVE E-MAILED YOU TO DISCUSS SPECIFICS IF YOU WISH!  HANG IN THERE!

THANK YOU!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I'm having the RnY done.  TriCare has been something else to get a straight answer out of any of them.....and when I called them originally, the girl I spoke to in Medical Management said she didn't understand what they needed and didn't need and told me to call back the next day to talk to the RN working on my case..............when I called back ...which I ended up calling back SEVERAL times, I never got to speak with the case manager, just anothe person in Medical Management who just 'quotes' what is on the screen and one quoted the April 2006 revision..............which even included obesity for over FIVE years??  Give me another five years and I won't be able to walk! I'll check my email when I get home this evening............I check the board on a regular bases at work......... Thanks again.............!!! Jacquie