Tricare Prime North question

Hello!

I was wondering if anyone has had the WLS surgery with Tricare Prime without going through a MTF.  I would like to know what the approval process was like.  I have no known co-Morbilities.  Not sure if I meet the 200% over my ideal body weight category.  I am 5'3 and I am suppose to be between 123-145.  Not really good with figuring this stuff out.  So if anyone out there can help me I would be greatful!

Thanks

Jessica

 
It really goes by your BMI more than anything and here is a BMI calculator:

nhlbisupport.com/bmi/bmicalc.htm

MTF... meaning on base vs. off?  What little I know is that they will approve a sleeve ON base but not off.  I see a lot of people posting that they are unable to have that particular surgery type because of this but (and please someone, correct me if I am wrong) they will approve bands or bypass.

Most ins co's want you to have a BMI of 35 or greater with specific comorbidities or a BMI of 40 with or without comorbidities.

What is your BMI and what surgery type are you interested in getting?

Hello! Thanks for replying! My BMI is 61 and I was intrested in the RNY.  Thanks again for your help :)

Jess

 
I believe you should qualify based on your BMI alone.

May I ask you to rethink bypass?  For a BMI of 61 you'll want to lose quite a bit and usually bypass buys you about 100#.  You will only malabsorb calories for 6-24 months but you will malabsorb nutrition for life.  Bypass has a very high failure rate, regain is a buggar.

One of the big problems with bypass is that over time often the stoma dilates.  There is nothing holding food in your stomach so you get the satisfied/full feeling.  When this happens people are always hungry and always eating.  Considering after a couple of years you are no longer malabsorbing calories that is when the regain starts.  Bypass has a minimum of a 20% failure rate at the 5 year point.  Risks and complications are pretty darn serious with bypass.  They are finding seizure disorders, reactive hypoglycemia, malnutrition, bowel obstructions, ulcers, and all kinds of problems with bypass long term.  Reactive hypoglycemia is another reason for weight gain in bypass folks.  Those are not issues I would want to deal with.  Thing is, you can have a text book surgery with the best surgeon in the business and the most compliant patient in the world and you still can have major, significant, life altering complications.  Also, with bypass you can never take NSAIDs again.  No Motrin, aspirin, none of those drugs.  What will you do when you are old and arthritic?  You are left with Tylenol and narcotics for the most part.

Have you done serious research into the sleeve or DS?  Please just consider looking at all your options, you have to live with this surgery for the rest of your life.  Nobody else, just you.  Get the best surgery type for you.

Sleeves are the safest surgery type long term, DS is the most effective surgery type long term. No seizure disorders or much of the other nonsense.

Are you a sugar and high fat person?  DS is your best option.  If you are not a grazer but you just eat mega meals then sleeve is a better pick.  With a sleeve your stomach is just smaller, same weight loss results as bypass without the dumping, bowel obstructions, blood sugar issues, and you can take NSAIDs.  DS is kinda cool in the sense that you malabsorb 80% of fat, 50% of protein, and about 40% of complex carbs.  So if you eat a bowl of ice cream you'll malabsorb 80% of the fat but you will absorb all the sugar.  No surgery type fixes flour/sugar.

There is a person that is very well versed in DS and bypass, her ID is MsBatt.  I would track her down and PM her.  She's great at explaining the DS anatomy vs. bypass anatomy and she can explain even better why DS really is superior in every way to bypass.  And with DS (unlike bypass) you will malabsorb calories forever.

Again thank you for your input unfortunatley I have to go with what my insurance covers.  The MTF on base dosen't do major surgeries and would refer me to the center I am going to anyways so RNY is what TRICARE covers and that is what I have to go with.  I have done a lot of research and I feel this is what is best. Again thank you for your input.

Have a nic day.

Jess

 
No, you do not have to go with what your insurance covers.  People appeal their surgery choices all the time and get the surgery choice they want.

But, you have to do what is right for you.  If you want RNY, go for it.

Hello there. I've seen many of your post advocating DS surgery. I've read a lot of good things about it and I was considering having the DS. I'd be a revision FROM a VBG done 22 years ago. Anyway, like Jess said, TriCare does not cover the DS.

I did not know there was any way to appeal a surgery choice. Have you heard of Tricare Prime insurance letting someone who appealed the RNY choice to a DS?

The doctor I am thinking about does the DS but they said he only does it if you are 600 pounds or over and thank God, I don't qualify for that weight.

If you have information as to how to appeal Tricare Prime and have them approve a DS, please advise.

Also, I was told a couple of years ago via an endoscopy that I had a duodenal ulcer. Not sure if that would mean anything as far as getting a DS?

Thanks for your help and advice.

 I'm sorry, TriCare and Medicaid are the two ins co's where appeals do no good. :o(

This is what I have learned using Tricare and getting denied:

You have to have a high BMI
You have to have at least 1 comorbidity
You have to be at least 100 pounds overweight (using the metropolitan life weight chart)

I'm 4'11" with a BMI of 42.6, weigh 212, have sleep apenea and pre-diabeties and was denied.  I'm going to try to appeal but they don't make it easy.

Well my BMI is 62 and i am 5'3 and i weighed at the time of my first appointment with the surgeon 350.  If you have no comorbities you have to be 200% over your ideal body weight which i do meet.  I have since talked to others that have tri care prime north and they have had no issues so i can help for the best :) thanks for your response.  I have my second appointment with the surgeon tomorrow.  I have done the checklist that my surgeon has provided and tomorrow we should be scheduling my surgery date.  Good luck with your denial :)

Jess