Tricare Changing Requirements?

[keepIToff 6]

I was told last week from my surgeons office that they heard that Tricare's requirements may be changing. Instead of the 3 months of dietary consoling it could be going to 6 months. Has anyone else heard this same news?

[Short and Chunky 230]

I was told last week from my surgeons office that they heard that Tricare's requirements may be changing. Instead of the 3 months of dietary consoling it could be going to 6 months. Has anyone else heard this same news?

[Short and Chunky 230]

I have Tricare and I had my surgery 7-7-11. I was not required to wait 3 months for any dietary counciling. I did have steps to go through but they were standard medical tests. Check with Tricare in you area and inquire yourself. When you do that, you will get the straight info,. Good Luck

[subsurfcpo 1]

Same here. My date is Monday and if there are changes they haven't happened yet.

[Fat-2-Phat 1]

I have Tricare Prime (in the North Region) and they require 6 months of supervised dietary/nutrition courses. While I wish it were only 3, I'm kinda glad it was 6, for it gave me time to process through everything and also the time to 'reset' my brain to begin implementing strategies for post-op success.

[SYRREHS 1]

So I've been going through the steps with my doctor for the surgery and I too have TriCare Prime.... I've had the dietitian evaluation, the phycological evaluation, medical clearance from primary doctor, met with the surgeon twice and last week they submitted the papers for approval. Well within a few days the authorization was denied... saying not medically necessary.... So I call TriCare asking why?????

I said to the customer service agent, "Why would my doctor submit for the precedure if he didn't feel it to be medically necessary?" Also, I asked was there another reason and she said because there was no record of me having any medical treatment such as; Weight Watchers, Jenny Craig and so forth. So I let her know that I have not gone through those programs because I can not afford them for they are very expensive. I've tried Slim Fast, Patches, Dexatrim, Acai berry, counting calories, food log and so forth. I also said that the website for TriCare does not state the medical weight loss programs as a requirement. It says; 100 lbs. over ideal weight and atleast one associated condition; such as high blood pressure (in which I have).... Is 200 % or more over ideal weight or Has had intestinal bypass or other surgery for obesity.

In another area regarding Bariatric surgery it says the Lap Band is a covered benefit that requires prior authorization and medical necessity review. Pre-surgical psychological evaluation and testing is covered. Pre-surgical nutritional counseling should be performed by staff in the provider's office and is not covered if requested separately. No mention of medical weight loss programs.... All she could say after that is that I can appeal the denial and that she can not see what a beneficiary sees on their side of the computer system.... GGRRRRR

I put a call into my doctor (surgeon) to find out if they have come across this before. I left a message and I'm awaiting a reply.

I know I'm going on and on but this is driving crazy..... Has anyone heard of this requirement for TriCare?

[keepIToff 6]

I have Tricare Prime (in the North Region) and they require 6 months of supervised dietary/nutrition courses. While I wish it were only 3, I'm kinda glad it was 6, for it gave me time to process through everything and also the time to 'reset' my brain to begin implementing strategies for post-op success.

Tricare and my surgeon have been telling me since I started this adventure in July that it was 3 months, and the surgeon has done many Tricare patients in the past on three months. Just was wondering if anyone is hearing things have changed. I am continuing on with my dietary just in case it is actually 6 months now so I don't have to start all over. I meet with my surgeon again on the 27th to review everything then get my EGD done, and not look forward to that day.

[Damander 11]

It appears that the requirements for different Tricare regions are different. I am Tricare Prime (south) and there is no supervised diet. I just finished my last test today and when the results come in they will be submitting to Tricare for approval. Obviously seeing as we are all different regions here, I would call Tricare yourself. They will be able to tell you exactly what is going on because none of what you are going through applies to us, so we have no idea how to help you

Good luck!

[DawnH 9]

I was told last week from my surgeons office that they heard that Tricare's requirements may be changing. Instead of the 3 months of dietary consoling it could be going to 6 months. Has anyone else heard this same news?

When I started the process the end of May to have surgery I didn't have to (had surgery Sept. 12th) but my friend started the process about 3 months ago and she now has to do 6 months so for us in the Tricare West region it is 6 months but only recently.

[formykids2 4]

This whole tricare thing is very frustrating, but... there is NO supervised diet time requirement listed in the tricare policy manual. The requirements have changed recently and they are no longer the 100lbs over or 200% over, but bmi 35-39.9 with comorbids and 40+ without. The HUGE change other than that is they now require proof that you have tried and not been successful with other weight loss endeavors. That being said... there is not set time frame but you have to have documentation of being followed by your pcm. If you have a dietitian at medical or anywhere else that suggests a certain diet, get a copy of it and see your pcm for a couple of months for documentation of weigh ins. You can even do jenny craig or weight watchers or whatever, they dont care what you do, but that you are actually doing something to try and that your dr is following you and keeping track of how much you do or do not lose. I can say all of this because I just had my surgery based on the new policy and that is what the people at Tricare Management Activity stated. You also can not just have a dr throw you on weight loss pills, they will not accept that. You can take their meds, but you must document a diet that you are trying too. For my approval I sent in the paper from the nutritionist at our base, had monthly weigh ins with my dr and even though I was required to lose 10% of my excess for my surgeon and was successful with that loss, they were able to state that I was NOT successful at adequate loss for my bmi and comorbidities to be helped. I know it seems like a pain, but tricare really is one of the easier insurance companies to get this covered. The new policy is on the tricare. mil site under tma and policy. It is in the surgery section and I believe policy 13.2 for morbid obesity. Please let me know if you have any questions about my experience and I will be happy to help!!

[Damander 11]

This whole tricare thing is very frustrating, but... there is NO supervised diet time requirement listed in the tricare policy manual. The requirements have changed recently and they are no longer the 100lbs over or 200% over, but bmi 35-39.9 with comorbids and 40+ without. The HUGE change other than that is they now require proof that you have tried and not been successful with other weight loss endeavors. That being said... there is not set time frame but you have to have documentation of being followed by your pcm. If you have a dietitian at medical or anywhere else that suggests a certain diet, get a copy of it and see your pcm for a couple of months for documentation of weigh ins. You can even do jenny craig or weight watchers or whatever, they dont care what you do, but that you are actually doing something to try and that your dr is following you and keeping track of how much you do or do not lose. I can say all of this because I just had my surgery based on the new policy and that is what the people at Tricare Management Activity stated. You also can not just have a dr throw you on weight loss pills, they will not accept that. You can take their meds, but you must document a diet that you are trying too. For my approval I sent in the paper from the nutritionist at our base, had monthly weigh ins with my dr and even though I was required to lose 10% of my excess for my surgeon and was successful with that loss, they were able to state that I was NOT successful at adequate loss for my bmi and comorbidities to be helped. I know it seems like a pain, but tricare really is one of the easier insurance companies to get this covered. The new policy is on the tricare. mil site under tma and policy. It is in the surgery section and I believe policy 13.2 for morbid obesity. Please let me know if you have any questions about my experience and I will be happy to help!!

I did go and review the manual and you are absolutely right about this. No one has mentioned this to me and my surgeon said that I shouldn't have any problems getting approved, so we shall see. I have not done any commercial weight loss programs except for Hcg and that doesn't count. It's so frustrating and I am so nervous that I will not be approved for this. Sigh..

They have sent me for so much testing, I have racked up about 7k in tests for the bariatric center so to me, it seems silly that they would deny me after they paid for all of that you know? The way I see it, they should approve all overweight people because they would be paying less for dr visits and CPAPS etc in the long run, you know? Ahh.. oh well.. I guess I'll stress about it for another couple weeks. Thanks for bringing this to my attention!!

[SYRREHS 1]

I was able to find this on the TriCare.mil site but, I still can not find where they have the duration for the non-surgical medical treatment i.e. Weight Watchers, Jenny Craig or doctor's program. Has anyone seen this on the website? I have also seen the change since I last checked (in which was just a few days ago) that the word, "all" is listed instead of "or" and it's underlined......

FAQ HomeNew Search

Frequently Asked QuestionsDate of Last Update: 10/11/2011 9:23:24 AMDoes TRICARE cover bariatric surgery to treat morbid obesity?

Yes, TRICARE covers bariatric surgery if you meet all of the following conditions:

1. You're at least 18 years old or you provide documentation of completion of bone growth.
2. You were unsuccessful with non-surgical medical treatments for obesity. Your medical records must show your failed attempts.
   1. Diet programs, such as Weight Watchers®* and Jenny Craig*, are acceptable methods of dietary management, as long as there's medical documentation of participation and monthly clinical visits with your doctor.
      
      *These programs aren't covered by TRICARE.
   2. Physician-supervised programs made-up of only weight-loss medication management, don't meet this requirement.

[*]You have proof of one of the following:

1. A body-mass index greater than or equal to 40 kilograms per meter squared (kg/m2); or
2. A body-mass index of 35-39.9 kg/m2 with one clinically significant comorbidity, including but not limited to, cardiovascular disease, type 2 diabetes mellitus, obstructive sleep apnea, Pickwickian syndrome, hypertension, coronary artery disease, obesity-related cardiomyopathy, or pulmonary hypertension.

http://www.tricare.mil is the official web site of the TRICARE Management Activity a component of the Military Health System Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church, VA 22041-3206

[Damander 11]

I never saw a duration, but I haven't done any of those programs..they were too damn expensive. All I know is this is really getting me down. I finally finished all my requirements, only to be told no?

I'm pissed.

[formykids2 4]

You don't have to do one of the programs, but they will accept them as your attempt IF you see your pcm for monthly weigh ins. You can use southbeach, taking, a Dietitian recommended diet or whatever, just have it documented what you are doing and make sure your pcm is documenting it and your weigh ins.

[Damander 11]

You don't have to do one of the programs, but they will accept them as your attempt IF you see your pcm for monthly weigh ins. You can use southbeach, taking, a Dietitian recommended diet or whatever, just have it documented what you are doing and make sure your pcm is documenting it and your weigh ins.

I haven't done anything other than regular diet and exercise and HCG, but like I said-they won't accept hcg since it isn't fda approved for weight loss. My PCM documented conventional dieting and exercise as well as my hcg, but that was it. I won't go back to my PCM because he laughed at me for my weight gain (Talked about it in another post). He was a new PCM and I just got him to send the referral to the bariatric center and I will switch pcms when this process is over.