PCM and Tricare prime

I need to know ....I am seeing my PCM on Thursady to ask about RNY. as couple of years ago I asked about Lapband and he said no..tricare doesnt cover it and besides He said he has only ever reffered 1 person for RNY. so He if tells me no then what can I do. or where can i go??? I need this surgery I'm 5'4 and 288.  I want my life back and I've done a lot of research and know that yes there can be major complications, but I'm to the point of taking the risks involved.

Here is what Tricare says....so it wont cover the lapband.  My surgeon said they used to do it, but now for whatever reason they dont.  My surgeon does laproscopic rny.  My PCM told me that BMI plays a big factor in getting approved.  I believe it's anything over 40, but dont quote me on that one.  Here is a link to check yours.... http://www.obesityhelp.com/morbidobesity/information/planner +results.php#BMIreference So your PCM should have no problem referring you, but if they do, I would ask for another PCM and get a second opinion.  Also, if you have high blood pressure, diabetes or something of that nature, your weight/bmi could be less and you still get approved.

Gastric Bypass (Surgery for morbid obesity) – Limited Benefit – Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty may be covered when one of the following conditions are met (view Hospitalization Costs):

• The patient is 100 pounds over the ideal weight for height and bone structure and has an associated medical condition, such as diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.
• The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions.
• The following are not covered:
  • Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633).
  • Gastric bubble or balloon
  • Gastric wrapping/gastric banding (CPT code 43843)
  • Unlisted CPT codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

I had open RNY 3 years ago. I have tricare prime. If your PCM tells you no then I would request a change. It is a procedure that is absolutely covered, both open and laparoscopically. They also cover TT after you've lost 100lbs and are at a healthy bmi. I would definitely question your PCM as to why they will not refer you. (I have found that those who don't give referals are either biased towards overweight people and have no good reason or are concerned about money because the referal would be to a civilian doctor). Anyway, good luck. It was the absolute best decision of my life.

Sadly there are PCMs out there like you describe, I had one of them while still at Ft Riley.  My doc had lost weight (70+ lbs) the "old fashion" way and had no love for those who needed the tool.  He wouldnt even hear of it and sent me to the nutritionist.  I knew we were moving in a year once my husband was back from Korea so I waited until we got here to address it.  My first visit with my PCM at Madigan was an angel and said it's a very accepted surgery here that some are done on post and some are done in Tacoma and Olympia, and said all were good.  I liked his attitude right from the beginning, and had already set it in my mind that if I didnt like his answers, I would keep looking until I found one who would work with me.  Thankfully, I didnt have to go anywhere. So, to the original poster, dont take no for an answer.  If you feel you need this, then by all means do whatever it takes to get you there.  We'll be thinking about you, and let us know how it goes :o)

you all are wonderful on this site...thank you, I def. meet all the qual. My BMI is 47.9 I have sleep ap. arth. in several joints, depression, anxiety, and all this started when I turned 40. I want to be like I was at 25 when I turn 50, so I have 5 yrs to work with this. But would like to have started yesterday but I wnated to get all my ducks in a row and know what I'm facing first. Again thank you u are greatand I'll keep ya posted~ Cindy ~

First off my suggestion is switch doctors.  I am tricare prime and the doctor that did my surgery was no BS.  He said you need the surgery and we will get it for you.  And I was only 260 at 5'6.  Tricare approved me first time out and the only comorbities I had was Asthma.  Again I would recommend to you that you switch doctors that are more understanding of you.  Good luck, I hope it all works out.