5 Year Weight History Tricare Prime

According to the surgeon's office, tricare requires a 5 year history of weight (aka long history of morbid obesity) .  Does tricare require a 5 year history of "morbid obesity" for approval?  I thought the requirements were 100lbs with comorbity or 200lbs over.  I have yet to read anything on the tricare website that states anything about about a 5 year history.

I am a little nervous about this.  My problem is the past five years I have yo yo'd from 235lbs to 180 back  to 230lbs with an average of 190 most of the time. 

Did you give a 5 year weight history for tricare prime?   Has anyone been denied for not meeting the standards of the 5 year weight history? 

Any ideas on where I can find out this information?  I can't find it anywhere on Tricares guidelines for bariatric surgery. 

Thanks

I just had surgery in March and did not provide a 5 year history. Just make sure you look at the metlife table to make sure you weigh enough. I was denied at first for being 1.5 pounds under weight. They dont budge.

MMMMM.....thats interesting.  Thank you for your reply.  Looks like I am giving tricare a call tomorrow.  If tricare says it is not a requirement, should I give the 5 year history anyway and let them know it is not a requirement, or not give the history at all?  I would hate the give the extra information if it is not going to be beneficial to me and posssibly give a reason for denial.

It could be the surgeons requirement to have a history, although I specifically heard tricare prime requires this from the office staff.  I will find out soon enough.

Your right about the weight.  I just make it for my height of 5' 5 1/2"( with two comorbids), and from what I've heard tricare is a stickler for the weight thing....one pound under.....Denied.  I will do the best I can not to be under. 

Please make sure you fall within the weight guidelines...Use the Metlife table, find your height and use the medium frame (this is the default) if you are 100lbs overweight you will need comorbs, but to find out if you are 200% above the ideal weight take the lowest weight for your height and the medium frame and multiply by 2 and this will give you the minimum for the 200%.
 
Now for the history thing, I had to submit a 5 year history, and I made copies of my weight cards from Weigh****chers (which I had been doing off and on for that period of time).  If you have dr. notes great if not contact Tricare and find out exactly what they want.


I wish you luck

This is really interesting.  Two replies, one with a five year history and one without.
I will keep you updated and when I contact tricare. 

I have general doctor visits where they took my weight, so I am sure I can get those documents.  What I am worried about is the office staff said the insurance companies are looking for a history of morbid obesity for 4 out of 5 years, of which I do not qualify.  

By the way I did nutrisystem....maybe I should show the my bill...hehe.

Thanks for the reply.

Hi! Did you ever find out from Tricare if they require a 5 year history of obesity? I have Tricare Prime and have had a couple of office visits 2 years ago where I did not have a BMI of over 40. I am scheduled for my initial visit with the surgeon on July 16th.

I just got my approval with Tricare prime yesterday, and I did NOT have to provide a 5 year weight history. I don't know. Maybe it is different by state, or maybe your dr just wants it. Who knows. I wish you luck on your journey though. My surgery is May 12.

Your policy manual should have the requirements listed out for you.  You can usually access it online.

I have Tricare Prime and did not have to have a 5 year history of obesity.  It was never brought up by my surgeon or Tricare.  Unfortunately for me (probably fortunately) I have no co-morbidities and I did not qualify by Tricare's weight table.  As you have heard they use the MetLife table, medium frame, the lower of the two numbers multiplies by 2, that gives you the 200% if you have no co-morbids.  Well I was 5 pounds under that and was denied.  My surgeon filed an appeal because my BMI was over 40 and as a general rule that qualifies you for surgery with no co-morbids ....but not with Tricare.  They don't seem to care about anything except that weight number on the MetLife table.  Now if you are 100 pounds over and have co-morbids such as high blood pressure or sleep apnea you will be approved.  My appeal was denied.  I thought about a 2nd appeal but we are transferring in July and I don't think I will have enough time.  It's very frustrating because I've been going through a WLS program for 10 months and Tricare paid for all the visits to the nutritionist, psychologist, and physical therapist but when it came time for surgery they denied me.  I asked the Tricare rep why they paid for me to go through all this for 10 months only to deny me and she said I had to be evaluated.......total crap......I was 5 pounds off from day one and that's why I was denied.  My surgeon told them in his appeal letter that obviously they were not worried about proper patient care but dollars and cents.  I'm hoping there is a light at the end of the tunnel because we found out we are going back to Virginia and at Portsmouth Naval Hospital they have the biggest military bariatric program in the country and they use the normal criteria that if your BMI is over 40 you qualify.  So I should be able to have it done there for free....I hope.  The only issue there is I've heard the waiting list can be anywhere from a year to two years.....but I guess I've waited this long so what's a little longer...right??  Well sorry for getting so lengthy.  I wish you nothing but success and a speedy approval with Tricare.
Stacey Carse

What doctor are you going to? I'm also in Jacksonville, and the surgeon asked my PCM for a 5 year history, but didn't say that it was for Tricare.  Of course, we've never been anywhere for 5 years at a time, so my PCM gave the surgeon what he could.