TRICARE PRIME ASSISTANCE

I am 35 years old and contemplating RNY. Well, I am past the contemplation part, this is a decision that I am preparing for. I am 5'8 275lbs 42BMI. I have an appointment on Monday 3/5/07 to have my initial consultation. Now, I have read the handbook and I understand what is covered, but i want to know if anyone has had any complications w/Tricare Prime and who is the best surgeon here in Phoenix, AZ. Thanks for everyones response in advance.

Hi, I guess i'll just share my experiance so far.  I am a little over 100lbs over my ideal weight, but i was denied by tricare because they did not find a co-morbidity which is required if you are not 200% over your ideal body weight.  I do plan to appeal. I talked to tricare and they told me that if i did not have any of the co-morbidities listed then I could appeal by asking my doctor to explain (with medical documentation) why the surgery is medicaly necessary.  I hope you have better luck then i did!

Wow, good luck on your appeal.

I am trying to understand co-morbidity. How do they determine if you have any or not? Do you have to have a medical history of it? What weight were you? I am currently 124lbs over my ideal weight.

Talk to you soon

I have never  heard anything about needing to be 200% over your ideal weight.... I understand their policy to be BMI of 40 with no co-morbidities or BMI of 35 with two.... I saw my PCM in August of 06, met all the criteria, got approved for the consult, went through all the classes and requirements of my surgeon, they requested for surgery, i was approved days later and had my surgery in October.  I had a BMI of 44, am only 100 pounds above my "ideal" weight and had no issues.  I will say that a girl I was going to classes with was Tricare Prime for retirees and they denied her stating they wouldnt go with her surgeon (same as mine) and I told her to fight it cuz I had just had my surgery with that surgeon and we were both tricare prime and there should be no differences in coverage at all.  Sure she has a copay and I dont, but that should be the only difference, needless to say she had her surgery in November and I was thrilled for her! Good luck to you!

I am thinking that maybe the difference is that we are in different regions. My BMI is 41 and I was denied. The denial letter came with their policy and they don't mention BMI at all. Just ideal weight and co-morbidities. They should have the same rules for all regions but i guess not .

I just wanted to say that I am also 100lbs over with no comorbs.  I did the sleep study and it was determined that I was borderline.  I also have had gestational diabetes with both of my pregnancies.  I guess that is not good enough.  According to Tricare I needed to be really sick to have it done.  I will eventually get diabetes and sleep apnea, but they want me to wait till I have it.....:)  I just wanted to share my story.  I switched insurance to Aetna so I hope I have better luck with them.   Good luck!!!  I have heard a lot of people got approved with no comorbs.  I just dont know how they did it.  I am in the North so maybe that is why....who knows!!!

Hello There, I also have Tricare Prime and was approved for gastric bypass on Valentine's Day!  I went to  my and told him that I was interested in WLS.  He then sent me to see the nutrionist on base (who told me that he was against WLS) and mental health.  Well I had one visit with the nutrionist and the mental health guy was TDY.  I made a f/u appt with my PCM.  Again told him I was interested in WLS and he gave me a referral on Friday 2/2/07.  I do meet their criteria for WLS I'm 5'5, weigh 250 lbs (BMI 41) and I have hypertension.  We are stationed at Cannon AFB in NM, so I was authorized to go see  a doctor in El Paso by the name of Dr. Bruce Applebaum this was on Monday 2/5/07.  They wanted to review my records before they would schedule me for my consultation, it took three days for them to get my records (once I found out they needed them before I could go any further I called the tricare liason on base  EVERY DAY TWICE A DAY once in the morning and once in the afternoon until my records was sent)  They got all of my necessary appts scheduled consultation, pysch eval, nutrition and education classes.  They also submitted everything to tricare and like I said in my first sentence I was APPROVED on Valentine's Day.  So it was a very easy process for me.   The only down fall is I have to travel 6 hours away to see Dr. Applebaum when there is a Bariatric doctor less than 100 miles away.  I hope this helps.  I wish you well on your journey, Letishia

If you go onto the tricare website they have guidelines as to what they consider when approving someone for WLS. Or you can also call and ask but sometimes they get snotty and won't want to tell you. They list specific things that they consider co-morbidities. They told me that I had to have one of the co-morbidities that were listed in the guidelines or else i would be denied. And I was.  When i got the denial letter there was a number that i could call with questions and when i called the lady that answered was really nice and she told me that she would advise me to appeal because if I don't have any of the listed co-morbidities then the review board would approve me if i was able to establish medical necessity. Think happy thoughts! :D Cristy

Thanks Christy,

I am now awaiting my surgeon referrel to start that process now. Went to see my PCM and that went very well.

Good Luck on your appeal, I know it will turn out to your benefit.

The only complication I had was during my referral process and my referral fell through the cracks but I was on it and got it cleared up with a quickness.  My main recommendation, KEEP YOUR DOCUMENTATION...  Good luck!