I'm 5'4" and 245 lbs with a BMI of 42, my doctor submitted my paperwork on last Friday and I was declined today. They said they needed more documentation, and that I dont have the comorbs that I need. I thought that as long as my BMI was 40, I didn't have to have comorbs, but it sounds like they are still using the 200% rule.

I have back problems, high cholesterol, depression and have to take sleeping pills to sleep at night, but none of that counts.

The Metropolitan weight chart leaves so much to guess at, Small frame is 114-127, so 200% would be 228 and medium is 124-138 or 248. I'm kind of inbetween a small and medium frame, my fingers do overlap slightly around my wrist. Do I really have to gain 3 lbs and then have them resubmit the paperwork?

5' 4" 114-127 124-138

Thanks Dave. I spoke with Coordinator and she says it is a Tricare rule. Tricare says it isn't. I am not getting a good feeling about this place. I will talk to the doctor on the 28th and see what he says. Tricare even told me to find a new doctor if they don't at least submit it. Could just be the coordinator didn't know what she was talking about.

Thanks again!

Tricare does not have a six month diet requirement. Go to the Triwest website and search the database for the exact wording of what they will and won't pay for.

Having said that, your surgeon may have a requirement. You'd need to ask them about it if it concerns you.

Dave

Thanks Dave. I spoke with Coordinator and she says it is a Tricare rule. Tricare says it isn't. I am not getting a good feeling about this place. I will talk to the doctor on the 28th and see what he says. Tricare even told me to find a new doctor if they don't at least submit it. Could just be the coordinator didn't know what she was talking about.

Thanks again!

Insurance Coordinators are supposed to be on top of the regulations. If this person isn't up to date, you definitely should bring it to the attention of someone who can change that. My experience with Tricare was that they are very specific about what they require, and what they will approve. In my case, it ws three days between date of submission, and when I was approved for surgery. No six month diet required.

If other thngs aren't stacking up, don't hesitate to move to a different clinic. You need to have confidence in your surgeon's team.

Good luck!

Dave

how do you figure out the 200% rule?

how do you figure out the 200% rule?

My guess is

Small framed--being able to get your hand around your wrist (I think)

100 lbs. is your ideal weight and you weigh 300

I had the comorbs so I fell into the 100 lbs. over group..