TriCare Questions - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

Army Wife · 10-26-2008, 08:14 PM

So, how does TriCare work in regards to WLS approval? My PCP seems to think there won't be any problems since he thinks it's what should be done medically, but I don't know anything about this...

What will TriCare require, if they do require anything? When do you find out if you're approved? How much will I have to pay out of pocket? I have TriCare Prime Remote.

Any info would be appreciated. PM if you'd like. Thanks!

cherbear716 · 10-26-2008, 08:54 PM

I got my GB with Tricare Prime. Here are the guidelines:

Is gastric bypass a TRICARE covered procedure?
Gastric bypass, gastric stapling, or gastroplasty, to include laparoscopic surgical procedures for gastric bypass and gastric stapling, and vertical banded gastroplasty are covered by TRICARE when one of the following conditions is met:

A. The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.

B. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.

C. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.

Shetaz0028 · 10-27-2008, 07:56 AM

Hi there,

Tricare seems to be different with each place and person. I posted a thread not to long ago with the updated requirements for Tricare North (that I am in) hereIs Tricare Prime North becoming nice? Check your area to find out for sure what you are required.

Charlie

cherbear716 · 10-27-2008, 09:33 AM

I forgot to tell you which Tricare I have. I have Triwest. I did get denied the first time because I didn't meet the requirements for Tricare but I did for the surgeon. My PCP completed the paperwork again and I was approved. Make sure the GB surgeon states that you are small boned. That's what I think got me denied the first time. The also use this to base you BMI and your Ideal Body Weight:

Better Ideal Weight Body Calculations

Army Wife · 10-27-2008, 09:42 AM

Quote:

Originally Posted by cherbear716

I forgot to tell you which Tricare I have. I have Triwest. I did get denied the first time because I didn't meet the requirements for Tricare but I did for the surgeon. My PCP completed the paperwork again and I was approved. Make sure the GB surgeon states that you are small boned. That's what I think got me denied the first time. The also use this to base you BMI and your Ideal Body Weight:

Better Ideal Weight Body Calculations

Thanks, I'm on TriWest, too. I am very overweight (314) and 5'6", and am actually small boned. However, I don't think I have any major medical issues, besides my endocrine stuff which is a totally seperate issue... Man, I hope I don't get denied...

ArmyWifeMEL · 10-27-2008, 01:08 PM

I have triwest, and you seem to be qualified, i weighed 330 pounds, i am 5'7'' and i was approved no prob. be careful though, because once you get denied once you have to write up an appeal and it takes them like six months to respond.

Army Wife · 10-27-2008, 05:52 PM

Quote:

Originally Posted by ArmyWifeMEL

I have triwest, and you seem to be qualified, i weighed 330 pounds, i am 5'7'' and i was approved no prob. be careful though, because once you get denied once you have to write up an appeal and it takes them like six months to respond.

Thank you. So who sends in the request for surgery? Is it my Primary Care Physician or the actual Surgeon?

readyornothereicome · 10-27-2008, 07:50 PM

I have Tricare South in LA and I went to my PCM for the referral to the WL Surgeon, I met with the surgeon and they submitted the paperwork to Tricare. That is pretty much the norm for Tricare South and I was approved no questions asked, but I met the 200% over my ideal weight, I have NO health problems yet, just starting to have knee issues. Good Luck and don't take No for an answer from them, I know tooo many people here at Fort Polk that have had it done

ArmyWifeMEL · 10-27-2008, 11:03 PM

Quote:

Originally Posted by Army Wife

Thank you. So who sends in the request for surgery? Is it my Primary Care Physician or the actual Surgeon?

my PCM referred me to my surgeon who then sent in all the paperwork for the actual surgery, however your PCM must send in the request to see the surgeon. with tricare, everything must be individually approved by tricare (but my PCM was by a civilian doctor, not on an army base so I don't know if it would be different). Just make sure that you don't have any special requests (for example they do not cover private hospital rooms, and that could leave you with a major bill)

NiftyFifty · 10-28-2008, 05:50 PM

Tricare approves in a week or less.....as they do others....Tricare has no regulations either than what your WLS will require...like blood tests, ekg..etc...I am going through Tricare and there were some problems there...nothing serious and I talked to my pc today and he is sending letter of clearance...these tests are very intense and best for your health and the surgery...but if you dont got anything suspicious...it will go fast...