Johns Hopkins/tricare Headache! Anyone Have Advice?

[IMakeArmyBrats5 0]

Hi there! I am throughly lost and no matter who I "officially" speak to, I get mixed answers. I was hoping to find some help here.

1. I am enrolled with US Family Health Plan-a Tricare Prime beneficiary plan, I'm in Marland, Ft. Meade

2. I make the 200%/over 40% BMI requirements of Tricare, 5 foot even and 243 pounds, small frame

3. I have some other issues such as severe GERD all my life (been overweight whole life too), asthma, osteoarthritis of spine, and family history of diabetes and stroke before age 50 (something my PCM says is a big red flag)

Here's the problem: They are wanting me to do this 6 month supervised "diet" which is basically anything I choose, but monthly weigh ins. If I lose too much, they wont approve me, if I don't lose enough they say I'm not trying and thus not showing initiative to the life style change that lap band requires.

I pulled up the policy for my insurance it says

USFHP Tricare Policy Manual Chapter 4.

A. BMI equal or greater than 40 or 35 with comorbidities AND patient was previously unsuccessful with non surgical medical treatment for obesity must be documented

But then it says right after that

Patient has evidence of either of the following:

1. BMI greater than or equal to 40

2.BMI of 35-39 with comorbidty

DOES NOT SAY ANYTHING ABOUT DIET RECORD! Nor does it say ANYWHERE about a 6 month diet!

I've called my insurance, but no one ever has a straight answer, and I don't want to go lose weight and then they don't approve me, that would be 6 months of waiting around for nothing.

Three of my friends and family members were approved in less than 2 weeks (some within 48 hours) without any diet (they were just on Tricare), even when they didn't meet the 40 BMI or 35 with comorbids. What am I doing wrong here?

[☠carolinagirl☠ 18,722]

i have tricare prime and when i started this procedure earlier this year, my dr said that my ins does have the 6 month wait. they do NOT. and this is according to the tricare people i dealt with. i have to prove (past weight attempts) but otherwise, it was very easy going and smooth to deal with.

it maybe due to your surgeons own requirement. but as far as i know, tricare (prime north) which is what i have, does not require any waiting period.

all the best to you.,

(also was approved in less than 48 hrs).

[FLORIDAYS 3,040]

I've called my insurance, but no one ever has a straight answer, and I don't want to go lose weight and then they don't approve me, that would be 6 months of waiting around for nothing.

I cannot help you with the insurance questions as mine wasnt covered even tho I had 217 lbs to lose.... but this statement puzzles me. If you lose weight and they dont approve... how is that waiting around for nothing? Any weight loss is wonderful!!

Good luck as you get the answers you need.