Question:
Anyone with Tricare Prime and BMI over 40 without comorbs been approved?

Just read surgeons letter to insurance and was not too impressed. All he stated for why the weight is a problem is because it interfers with my family life. I have no definite comorbs, I have back, knee,feet pain and Gerd. He did not even list the Gerd. I guess I need information as I am afaid I will be asked for appeal information next.    — Jan S. (posted on February 7, 2003)

February 7, 2003
Hiya :). I have TriCare Prime and can tell you that you don't need ANY co-morbidities IF your weight is twice what it should be. The chart that they use is the MetLife Height & Weight Chart. Find your height, then go down the MIDDLE row (for Medium frame, even if you're NOT a medium frame), and use the FIRST number in that column. FOr instance, I am 5'9", and that number for me is 139. So, as long as I weighed more than twice that (278), which I did by far, I would be approved. So, take a look at that chart and see if you can qualify by weight alone! TriCare Prime, no matter where you are located, has to use the same criteria. Good luck! :) SuzAnne in Utah
   — SuzAnne S.

February 7, 2003
I also have Tricare Prime and the criteria was different for me. Maybe they have changed it since I had surgery, but the handbook stated that you had to be at least 100 lbs. over ideal, or a BMI of 35 (with at least 2 comorbs), or BMI 40. I was approved with the 100 lbs. over (before I gained my last supper syndrome weight). I was no where NEAR twice my ideal weight. But like I said, they may have changed. I had a friend that was over 40 BMI and no co-morbs. She called herself a 'healthy fatty'. She had her sugery 3 weeks after I had mine. I hope it works out for you!
   — Cheri M.

February 7, 2003
Hi again :). I have to add that Cheri is also correct. When I responded earlier, I was going on the basis that there weren't going to be any admittable co-morbidities, so the only way to qualify would be weight-based. But Cheri is correct in what she said about the 100 pounds and co-morbidities also. I hope I wasn't too confusing :).
   — SuzAnne S.

February 12, 2003
This is the Tri-Care Handbook on-line. http://www.wpsic.com/tricare/handbook/part9.html It explains the rules for "Obesity Treatment". It helps to be well informed. Obesity Treatment TRICARE Standard coverage is limited to three types of surgical treatment: gastric bypass, gastric stapling and gastroplasty, including "vertical banded" gastroplasty, when one of the following conditions is met: A patient is 100 pounds or more over the ideal weight for height and body structure and has a life-threatening medical condition related to morbid obesity; A patient is 200 percent or more of the ideal weight for height and body structure, even without a related life-threatening medical condition; A patient has complications from a noncovered surgical treatment for obesity, such as intestinal bypass, and needs one of the three surgical procedures that are covered. TRICARE Standard does not cover any other services or supplies related to obesity or weight reduction. And non-surgical treatment of morbid obesity, such as wiring the jaws or special diets, is not covered. I was 100 pounds over weight with one co-morbid...high blood pressure. I was very afraid I would not be approved but received my approval with in a week of submitting the request. Good luck on your with loss journey. If you ever need to talk, please e-mail me. hugs, kim
   — Kimberly V.