Question:
I have tri-care prime and they are giving me a hard time please help

I weigh 335.lbs and i am 5'6 but since i dont have any of the following problems tri-care is giving me a hard time to have surgery... Please anyone who used tri-care help me. Other than my weight they say i am healthy. But My weight is my problem.... (high blood pressure, narcalepsy, severe arthritis or or be 200% over my body weight. I am two hundred pounds over, because my ideal weight is 117lbs that what is medicaly recommended. But the peoples ideal weight would be 207. My doc told me that i would have to be 450 to be able to obtain the surgery,,,,, :( Anyone please help.....    — thelma B. (posted on January 9, 2003)

January 8, 2003
Thelma, this topic came up on a plastic surgery list I am on, and someone responded that Tricare may be denying some elective surgery in order to keep their surgeons available for "other" things, if you know what I mean. But, that is not to say that you can't appeal the denial and be successful. My own opinion is that usually WLS is certainly more medically necessary than plastics, so don't give up. Contact Walter Lindstrom (www.Obesitylaw.com) if you must, as he may have more insight into what Tricare is doing right now, but definitely DON'T give up! Good luck!
   — Leslie F.

January 8, 2003
Thelma, I don't know why you were denied. I was 5'4 and 292 pounds and PERFECTLY HEALTHY and I was approved within 48 hours of my first request. Have you actually been DENIED by tricare? Or is your PCP just not submitting the paperwork for you? email me @ [email protected] if you'd like to talk more about it.
   — Virginia N.

January 8, 2003
Hi Thelma :). I also have TriCare Prime. I am almost 2 weeks post-op, but when my paperwork was sent in, I weighed 336 (and I'm 5' 9"). You should have NO problems getting approved! I agree with the previous poster who asked if your PCP is just not helping you out! I can even tell you exactly which number TriCare uses to determine your 200% over ideal weight (I hounded our TriCare nurses and had them explain the whole process to me). They take the MetLife table, find your height, and then use the FIRST number in the MIDDLE column (medium frame). They take this number and double it, and if you weigh more than that, you DO automatically qualify. Since you are 5' 6", you only have to weigh more than 256 pounds (128 X 2) to qualify. I would highly recommend calling your local TriCare and talking to the nurses (who are often the ones doing the approving) and asking them about it. Then get back in there to your PCP and let him/her know that you do qualify! BEST OF LUCK!!!
   — SuzAnne S.

January 8, 2003
Thelma , I would check with your pcm i am healthy and although my weight is over the recommended i have had no problems getting approval twice....call your local tricare office and see what they suggest ,,,,best of luck...i see my surgeon on 2/18/2003
   — A M.

January 9, 2003
I am a tricare patient as well. Do you feel your doc is supportive of this surgery? If not, educate or switch providers. Tricare says 200% or 100lbs overweight plus a comorbidity such as DJD(arthritis)high blood pressure, diabetes. You would be approved based on Tricare standards. Speak to your doctor. A lot of military physicians may not be up to speed on this. If you feel the doc is blocking you on this move on to a new doc. But, like I said, docs aren't always aware. Make sure you have documentation to back up your comorbities before they submit. Get xrays, bp readings Your doc is wrong on this one. Help him out or move on.....
   — Kris B.

January 9, 2003
Thelma, I called my local Tricare office after I read your posting. The nurse I spoke with says that it all depends on how your surgeon words your request for surgery. She said they take the weight& BMI and see if you automatically qualify- I would think you would- If the weight is a tad bit short they also look at how the weight is affecting you medically and how it affects your quality of life. She said most surgeons would not submit the paperwork if they did not think you would benefit for the surgery. I say, have the surgeon submit your paperwork-with your weight,BMI,medical problems and complaints. You keep saying your doctor- is this the surgeon or the PCM? If it is the PCM- he just need to request a referral for consult with a surgeon and the surgeon will take care of the rest for you-make sure you have proven Diagnosis when you go to the surgeon-sleep apne, arthritis.... Good Luck.
   — Jan S.

January 9, 2003
I agree with what the other posters said. The problem may be in how your doctor worded the referral. Or it might just be that you got someone who doesn't know what they are doing. I called tricare with a question before I went in for my initial consult and the person on the phone told me "we don't cover any kind of WLS"... well... I happened to have the Tricare manual fresh off the internet and I asked her to turn to page xx and LO, what have we here. DUH! Don't give up, sometimes it just takes talking to a different person! Heres a link to the Tricare handbook http://www.tricare.osd.mil/TricareHandbook/ and a link right to the page you need http://www.tricare.osd.mil/TricareHandbook/results.cfm?tn=31&cn=10 If they still give you hard time, talk to your doctor about getting a comorbidity/other health issue documented. Sometimes just back pain will do it.
   — Anne R.

January 9, 2003
I am pre-op awaiting surgery date in Germany. When this all started for me last month, my pcp said that Tricare now has a new format for listing comorbidities and getting it written wrong can delay the process. Also, according to Tricare Basic Program Benifits, Part 199.4 #15-B (page 49 on the web site) If the patient is 200 percent or more an associated medical condition is not required for this category. So if you are getting the run around, both you and your pcp need to contact Tricare and make sure of the new format. Hope this helps. From my understanding, Tricare almost always approves, tho with some it takes a little while longer, you know how the military is about being overweight!
   — Dreama C.