Need advice for Tricare south in Dallas, TX

I am a military wife on Tricare south prime. I was hoping to find someone from the same area (Dallas,TX) that has been through the plastics process with some sort of success on approval even if not everything. Getting a referral from my doc is not problem, but to who? Every surgeons office I have spoken to under the Tricare in network list seems to not want to even schedule an appt after I ask about them working with Tricare. I am also wondering if it is possible that the process is easier if I switch to Tricare standard. I was hoping to find someone that has had some sort of success in the same area so I can get some direction here.

I lost around 120 pounds. I think i need the thighs, arms, lower body lift and an augmentation/maybe lift. If anyone has any personal experience or a friend with personal experience that included approval in with Tricare in the Dallas I would be so thankfull to get some advice so I don't feel like I am fishing in the dark for answers.

 I tried with triwest and was denied. You can easily get referrals and visit a PS but the rules for surgery have changed recently. You can read the guide lines on the website. I would use them to visit several surgeons to help you decide who you fit best with. If you have any reason for an abdominal surgery like a hernia repair you might be approved for a pannie removal.  I wish I had good news but I guess money is tight and they aren't allowing as much. I do wish you luck and hope you can find a way to get approved. At least they will pay for consults . If you can call it a breast reduction instead of a lift they will most likely approve that.
Get documentation of rashes and medical problems with the extra skin and get your PCM to write a letter of medical necessity. I hope it works out for you.

Getting approval with Tricare is sometimes very difficult, but from what I have observed, at the very least you are going to need to have your skin issues well documented.  I helped a friend with an appeal last year.  They approved the panniculectomy but not LBL, thighs or breasts and she had months and months of records on recurring skin issues and other problems.  One of the things Tricare said in her denial was that they were looking for evidence the skin issues made her ill.  While I have read of people having other procedures (butt, thighs, etc.) the reality is that Tricare will generally only pony up for the panniculectomy and not even the full TT.  Tricare is also going to look at how far down the panni hangs.  I believe that is a big factor in whether or not ones gets approval.  Of course if you are having a hernia repair, or some other abdominal surgery at the same time I think it is easier to get approval.

Consequently, I would say that is your first step.  Getting your skin issues documented and treated.  You will want to do this over a period of months.  They are going to be looking for something like, "persistent and not responsive to less invasive treatment".  You want prescription medications.  For goodness sake, don't self treat, it has to be in your medical records.  And be sure that what your doctor writes is in the strongest possible language.  Second, step; get examined to see if you have a hernia.  But even the hernia repair is not going to get you approved if the panni does not hang far enough down.  The third step is to find a doctor who is experienced with dealing with Tricare and has gotten approvals in the past.  If you go the Tricare Standard route, you want to ask the doc specifically -- "do you accept Tricare assignment and do you accept the Tricare maximum allowable as full payment".  Tricare will come up with a number as the maximum allowable charge for a procedure.  Then when they pay the doc they will subtract your co-payments and deductibles from that payment.

You can find the policy on the Tricare website:  http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManua ls.DisplayManualSeriesInfo&ManualSeries=T3TPM  .

I used search term panniculectomy.  Or shoot me a PM with your email address and I will send you a copy of the policy.

As to the questions of whether prime or standard.  In my neck of the woods more doctors accept standard than prime so if you lived in Florida, I would say absolutely yes.  But that does not mean it will be easy to find a doctor willing to work with Tricare.  When I started my search, I could not find any of the plastic surgeons who accepted tricare in my area who would accept tricare for a TT/panniculectomy.  Yes, they were in-network providers, but that did not mean they had to accept tricare for everything.  I increased my search radius and found a doctor about 100 miles away who was willing to file with Tricare and accept what they paid.  Tricare denied me.  I did not file an appeal as I had identified another resource by that time. 

Since you are in Texas if you have no luck with finding someone who is willing to work with Tricare you might want to check into the University of Kansas Resident Training Program.  Someone has posted that they accept Medicare and generally a doc who accepts Medicare will accept Tricare Standard.  I do not know about Prime.  You might also want to check to see if the program at Tulane accepts Tricare.

Just let me know if there is anything at all I can do to help.

Red