Hi guys, I really need some advice!!

I am 25 years old, I am 5'1" and I weigh approx. 208 lbs (last time I weighed; weeks ago). As far as I know, I don't have any other health issues (aside from being fat and VERY uncomfortable) that I know of (I go to the DR in the am) but I am addicted to food.. I don't quite know my body type, I would say I'm small framed but the Metlife site says I'm medium.. I want the surgery. I've tried every diet possible, my latest was the HCG diet.. I dropped 60 lbs (from 230) and kept it off **kinda** until I got pregnant, gained a bunch of weight afterward and I can't get it off for the life of me. In order for my insurance to cover it (Tricare) I have to meet all of these requirements..my question is there anything that I can tell my Dr that will convince him that I need the surgery and that he agrees I should have it? This is just my regular physician to talk to him about my weight.. ugh...I just don't know what to do..

Any help would be greatly appreciated!!

Have you decided on a bariatric doctor yet? You should probably start there. His office will be able to tell you exactly what your insurance's criteria is. Some companies require a 6-12 month supervised diet. If you've been going to your PCP for any length of time he should be able to help you bypass that. He knows your history. Especially if you saw him during that 60 pound loss before your pregnancy. With a BMI of 38 you shouldn't need co-morbidities. Those are usually required if your BMI is under 35.

If you haven't decided on a doctor go to the main page here. Scroll down to Find a Surgeon. Click on your state and scroll to your city. They should all be listed there. Good Luck.

My experience has been that BMI's between 35 and 40 do need co-morbidities for many insurance companies to approve.

Dave_NW is pretty up on Tricare info. There are also tons of posts about Tricare here. Do a search and see what you can find. The search can be cumbersome, but give it a whirl.

Here is a link to what is said to be a recent change to Tricare's definition of Morbid Obesity for coverage. To have a BMI equal to or great than 40, you need to weigh 212. So, I am not suggesting fraud, but do not do what we usually do when seeing our doctors--dress as lightly as we can. Wear jeans, a shirt, and a sweatshirt over it. Wear your heaviest shoes, and when they measure your height, don't stretch yourself to as tall as you can possibly make yourself. Have a big Breakfast and drink loads of Water. We are so used to trying to minimize ourselves. In this case, you don't want to do that.

5'0" and 208 is a BMI of 40.6, 5' 1/2" and 209 is 40.1. You are right on the cusp of a 40 BMI.

http://www.federalregister.gov/articles/2011/02/14/2011-3207/tricare-program-surgery-for-morbid-obesity

it states:

( Covered bariatric surgical procedures are payable only when the patient has completed growth (18 years of age or documentation of completion of bone growth) and has met one of the following selection criteria:

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(1) The patient has a BMI that is equal to or exceeds 40 kg/m 2 and has previously been unsuccessful with medical treatment for obesity.

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(2) The patient has a BMI of 35 to 39.9 kg/m ^[2] , has at least one high-risk co-morbid condition associated with morbid obesity, and has previously been unsuccessful with medical treatment for obesity.

I haven't started looking for a bariatric Dr yet because it is my understanding that I don't have to see a bariatric physician with Tricare. I may be wrong, but I've been looking on the sites left and right and since it has become an approved surgery, all that is required is the PCM to refer it, and then the surgeon do a consult and agree with the PCM. Hopefully that is the case. I know for sure that Tricare doesn't require a supervised diet of any length which I am grateful for. I just switched to this PCM because we moved to a different city for my husbands recruiting duty, but it is still S&W and they should be able to see my history right there on the computer without me having to sign a consent to get medical records. Thanks Cocoabean, I will definitely "dress up" for my appointment tomorrow, to us overweight people we think "what's a few more pounds? I'm fat now, a couple more pounds won't change that!" but I know insurance companies don't see things like that. I'll post on here how my appointment goes and what needs to be done in order to start the process. Hopefully I don't have to gain more weight in order to qualify, though if I do I am pretty sure I'll gain it without even trying.. sad..

Thanks for the help everyone!!!

Hi I'm 5'1" and 230 lbs, my BMI is 42.3! I am trying to stay where I am so that my BMI doesn't drop but even if it does, I am prediabetic and have hypertension.

I'm almost sure u will have to meet with a surgeon before your surgery. Alot of insurance will tale a surgeons request before the PCP referral. Ultimately, his letter will stand put mores. But all in all, 99% of the time if your PCP write a referral for the surgery , the surgeon will back it up and

Insurances seem to approve it easier when from a surgeon

as well. Good luck!

Dave_NW is pretty up on Tricare info. There are also tons of posts about Tricare here. Do a search and see what you can find. The search can be cumbersome, but give it a whirl.

Here is a link to what is said to be a recent change to Tricare's definition of Morbid Obesity for coverage. To have a BMI equal to or great than 40, you need to weigh 212. So, I am not suggesting fraud, but do not do what we usually do when seeing our doctors--dress as lightly as we can. Wear jeans, a shirt, and a sweatshirt over it. Wear your heaviest shoes, and when they measure your height, don't stretch yourself to as tall as you can possibly make yourself. Have a big breakfast and drink loads of Water. We are so used to trying to minimize ourselves. In this case, you don't want to do that.

5'0" and 208 is a BMI of 40.6, 5' 1/2" and 209 is 40.1. You are right on the cusp of a 40 BMI.

And don't forget to throw some ankle weights on under your jeans!

So I just got back from my Dr. visit. Leave it to me to pick a PCM that doesn't recommend the lap band surgery. My weight today was 210, which is good in terms of being closer to having insurance approve my surgery. I go back in the morning for all of my lab work to make sure there isn't an underlying issue with my health for the weight gain (i know there isn't) and he recommends that I try medication such as amphetamines for weight loss before I go the surgery route, but said when I return to him in two weeks, If I still don't want the medication and would like to be referred to the surgeon that he would do so for me. Medication..amphetamines..for what? So I can be addicted to those instead of food? No thanks! My father is an addict and I am not taking any chances! So when I go back in two weeks, I will get a referral to a surgeon and hopefully be approved for this!

In a way (i know its a horrible way to think) I kinda hope that when my labs come back, I have some kind of co-morbidy that will make me eligible for the surgery right off hand without the hassle.

My entire family is obese, with a few members that are morbidly obese.. I NEED this surgery. I don't want to be morbidly obese as well

So I just got back from my Dr. visit. Leave it to me to pick a PCM that doesn't recommend the lap band surgery. My weight today was 210, which is good in terms of being closer to having insurance approve my surgery. I go back in the morning for all of my lab work to make sure there isn't an underlying issue with my health for the weight gain (i know there isn't) and he recommends that I try medication such as amphetamines for weight loss before I go the surgery route, but said when I return to him in two weeks, If I still don't want the medication and would like to be referred to the surgeon that he would do so for me. Medication..amphetamines..for what? So I can be addicted to those instead of food? No thanks! My father is an addict and I am not taking any chances! So when I go back in two weeks, I will get a referral to a surgeon and hopefully be approved for this!

In a way (i know its a horrible way to think) I kinda hope that when my labs come back, I have some kind of co-morbidy that will make me eligible for the surgery right off hand without the hassle.

My entire family is obese, with a few members that are morbidly obese.. I NEED this surgery. I don't want to be morbidly obese as well

Well, the PCM might not like it, but is at least willing to refer you! Explain you considered the drugs, but that addiction runs in your family and you are not interested in something that will only work for as long as you take it. The bloodwork will be needed anyway, so no harm, no foul. Did they check your height? You might discover you are not as tall as you think, and your BMI will be 40 or greater. Then, done deal.

Keep us posted.

Since your PCM won't recommend the lap-band, why not try the Bariactric route? I'm not with Tricare but I haven't even consulted my PCM and have been using the Dr.s through the bariactric clinic (True Results). Try to see if their is one in your area. They'll make sure you have everything in place before submitting you through insurance. That way, you're not dealing with the insurance companies yourself. The insurance will try and find any loop hole to deny you.

I don't know what you can do if you don't have a co-morbidity. I have hypertension and still had to have a letter from my PCM stating that I had hypertension, even though I am on 2 different medications, in order to be approved through tricare. I hope your PCM will be able to help you, if he doesn't look into getting a different PCM. It's an easy process through tricare you if meet the standards, the longest part is waiting for the appointments of the psych eval and nutritionist. Good Luck.

So I just got back from my Dr. visit. Leave it to me to pick a PCM that doesn't recommend the lap band surgery. My weight today was 210, which is good in terms of being closer to having insurance approve my surgery. I go back in the morning for all of my lab work to make sure there isn't an underlying issue with my health for the weight gain (i know there isn't) and he recommends that I try medication such as amphetamines for weight loss before I go the surgery route, but said when I return to him in two weeks, If I still don't want the medication and would like to be referred to the surgeon that he would do so for me. Medication..amphetamines..for what? So I can be addicted to those instead of food? No thanks! My father is an addict and I am not taking any chances! So when I go back in two weeks, I will get a referral to a surgeon and hopefully be approved for this!

In a way (i know its a horrible way to think) I kinda hope that when my labs come back, I have some kind of co-morbidy that will make me eligible for the surgery right off hand without the hassle.

My entire family is obese, with a few members that are morbidly obese.. I NEED this surgery. I don't want to be morbidly obese as well

I am just trying NOT to lose weight (i know that sounds AWFUL) until I can get that referral to the surgeon and talk to him about it. I have been doing extensive research on TriCare Prime and its coverage, and on the Federal Register, there is an article dated 02/14/11 that states that Tricare will start going off of BMI instead of the MetLife weight chart. My BMI is 39.8, by the time I make it to the surgeon, I'm pretty sure that will be higher; I have a small body frame and other small health issues. I don't know if I have a comorbity, I will get my lab results when I go to my dr next week, but after all the reading that I have done, I am sure that I will be able to be approved. I hope so at least. If I get denied, I will appeal until I can no longer appeal an hopefully that works.

I will continue to post on this topic to keep everyone informed about my journey and hopefully help others with theirs if things go my way..so here's to hoping!

So I just had my two week checkup with my dr to go over my lab work. He is running more labs because my thyroid levels are borderline high and my iron is low but other than that, no health issues. I am attending the required bariatric surgery seminar tomorrow night before I can get in with a surgeon for a consultation, but I'm telling you after all is said and done, I am going to find another PCM. When I told him again today, that no I don't want any medication I want a referral to a surgeon, he went out to talk with his colleagues and I heard him talking about the fact that I gained 30 lbs in 8 months..and laughed. So, I have gained weight but that is no reason to laugh at me. I am so furious about this.

So I just had my two week checkup with my dr to go over my lab work. He is running more labs because my thyroid levels are borderline high and my Iron is low but other than that, no health issues. I am attending the required bariatric surgery seminar tomorrow night before I can get in with a surgeon for a consultation, but I'm telling you after all is said and done, I am going to find another PCM. When I told him again today, that no I don't want any medication I want a referral to a surgeon, he went out to talk with his colleagues and I heard him talking about the fact that I gained 30 lbs in 8 months..and laughed. So, I have gained weight but that is no reason to laugh at me. I am so furious about this.

I understand your anger, your doctor sounds a lot like my old one! I can tell you that the drugs don't work long term and can make you feel like total crap when you are on them. I would find myself eating to try to feel better!

I have Tricare Prime, and the whole process was pretty easy. I didn't have to do the 6 month supervised diet. From start to finish the whole process was about a month and a half. Good luck to you!!!

I am hoping that after I attend this seminar tomorrow, things start running smoothly. Today I hit a BMI of 40 and while I know that Tricare doesn't go off of BMI, I am hoping and praying that I get approved for this. I REALLY need this.