Tricare now approves lapband

[ras141414 0]

I assume that that the PCP has to ensure that the patient meets TRICARE REQUIREMENTS first before the referral is written up.. I would take a copy of the transmital with me to the appointment with the PCP. When I took a copy of my Lap Band Surg procedure that was done in Mexico and had it put in to my medical folder, they didnt have a clue as to what procedure I had done. WHen I asked my PCP about getting referred out to see a DR.in the US again she didnt have a clue as to what I was talking about.. GO IN WITH ALL YOUR GUNS first.. Tricare is new at this and the better you are informed the more they need to be informed.

I just want TRIcare to cover my fills and maintenance when I need it.. PLUS BCBS is my back up now.. SO I know I wont have any problems getting insurance to cover me..

GOOD LUck

DIane in San Diego

[mommakatx2 0]

I assume that that the PCP has to ensure that the patient meets TRICARE REQUIREMENTS first before the referral is written up.

Actually my PCM approved my referral without checking the Tricare requirements at all. It's not their job to determine if you are eligible, that is the surgeons job. That is my understanding. Many times procedures are referred and approved on a case by base basis, even when there are "requirements".

At this point, Tricare is not approving anything. It is my goal to complete all the necessary appointments and such so that when the date does come through all my surgeon has to do is submit the info.

And, if all else fails...there's always Mexico :biggrin1:

[mgordon1 0]

Hi Everyone - I have been busy with family, holidays and on the phone with Tricare, it has been a journey. After talking to Tricare Management Office- TMA (headquarters in D.C. - that actually approved the change), the Triwest Regional Office (the office that overseas Triwest) and to the Triwest Beneficiary Office, they finally told me that the change should be updated in the manual by 1/15/08 or sooner. :whoo:

I am crossing my fingers, toes, throwing up prayers and anything else that may help to get this through any sooner. Quick note, when I originally spoke with TMA (headquarters in D.C) they wondered how I recieved their phone number, I kindly told that google works wonders :-)

Then when I expressed the urgency of the nature, my surgery is schedule for Jan 16 and I found a surgeon who is willing to take the insurance, then they tried to tell me about the RNY. I was a taken back considering this was not a medical professional and he had not reviewed my records, however, cooler heads needed to prevail because I wanted the information more than I wanted to tell him a thing or too. I informed him that my doctor and I decided that this is the best course of treatment for me and therefore this is the direction that I was going in. Then he decided to help:heh:

I also got a denial, however, Triwest also has all of my records in their computer so TMA, Tricare Regional office and the Triwest Beneficiary Office knew that I was serious and was not going away.

If anyone else has had any other luck with Tricare, please post

HAPPY NEW YEAR EVERYONE - WE WILL ALL BE HEALTHIER IN 2008

[Jesusislove 26]

Hi, this is awesome news. I checked this forum to see if it had been approved because Tricare tried to call me out of the blue. I had a referral that had been cancelled, they were calling me, so I might be one of the first approvals.

[ras141414 0]

HOPE all goes well for you and soon you will be banded

Diane in San Diego

[mommakatx2 0]

Good luck Trell! Let us know what you find out!

[Yorkie_Luv 0]

The requirements that I had to do for Tricare for LapBand were; a nutritionist eval, a psych eval, a TSH level test (blood test to check thyroid), a H-Pylori test (blood test to check for stomach ulcers), and a letter from my PCM saying that I am cardio and pulmonary wise healthy for the surgery. I had no problem getting any of that and had it all done within 2 weeks. Here was the snag....I've been on Tricare Standard for a year and switched back to Prime (just effective Jan. 1) so that I wouldn't have much out-of-pocket for the surgery. I had all the letters and tests done under Standard so now I have to go on base to my new PCM, but just to get a letter about the cardio/pulmonary things. All my other tests and letters are acceptable. Tricare covers the band whether you are Prime or Standard, but since I switched in the "middle" they had to throw in a kink in my otherwise smooth process!

[mommakatx2 0]

Whoa, whoa, whoa, Yorkie!! More details are needed! How did you get approved? May I ask what your BMI is? When did you start the process? Where are you located and where are you having your surgery?

Sorry for all the questions but you're the first person I've ever heard of being approved by Tricare for the Lap-Band.

I hope you don't mind sharing!

[mommakatx2 0]

One more question...do you have an idea of what your out-of-pocket expense will be?

[Yorkie_Luv 0]

Oh Gosh, I didn't mean to make my post misleading. I haven't been banded yet. :omg: I am in pre-approval. The insurance coordinator at my surgeons office submitted all of my tests and paperwork to Tricare and that is when Sue from Tricare called her and said that I need the letter from my on-base PCM. I'm just waiting for that and then should have an approval. I totally qualify according to Tricare. I have a 39.9 BMI with several comorbidities. The insurance lady at the surgeons office said that I needed those things BEFORE an approval so she had me go ahead and do them. If you have questions...call Sue at Tricare Medical Management...not the CS bozo's that answer at Tricare...they are clueless! So sorry if I mislead you all and got you all excited! I hope to be banded in Jan. though! :clap2:

[Yorkie_Luv 0]

Also wanted to add that I had my first appt. with my surgeon (that Tricare approved me for) on Nov. 18 so that's when I started doing all the tests, etc. just to give you an idea of a time frame. I am in Maryland and my surgeon is Denis Halmi in Arlington, VA. They had no openings on base at Walter Reed....thank God!!! :whoo:

[mommakatx2 0]

Thanks so much for clarifying! It sounds like you're on your way! I'm worried about the comorbidities, though. You can see my BMI in my siggie and I only have asthma and shortness of breath. I have painful joints but nothing I've been seeing anyone about (just twice in the last 3 years). According to policy, though, for gastric bypass surgery Tricare only requires you to be 100lbs over ideal weight with *one* comormidity.

Good luck Yorkie and please keep us posted!

[minpinmom 2]

Did Tricare pay for your Nutritionist? When I first stared this well over a year ago, the surgeon's office had me do a psych eval, and see a nutritionist. I did the psych eval, however when I went to find a nutritionist, Tricare said they aren't covered, so I asked why they were requiring one and they said they weren't - then I found out that they weren't covering the band - I am wondering if the surgeon's office is asking for the "traditional" requirements since Tricare doesn't have anything posted for Lapband yet.

BUT please let me know about your nutritionist, here they are 100-150 an hour. I would actually really like to go before and after the surgery, I just can't handle 100 more than maybe 2 times.

[dallman 0]

We are no longer on the no pay code list as not approved. Hope to see the change in the manual shortley. There is a new list out today dated as of Jan 1, 2008. One more step down a few more to go.

Don

[Sgt Bob 1]

I'd just like to say a big thanks to all the people who have been doing all the research and keeping us all up to date on whats going on with Tricare. It can be a daunting task trying to get that kind of information and a lot of people would have simply given up.

THANKS!!!(thats a big thanks!):whoo: