Hey all,

I'm in the process of trying to get approval for surgery from tricare, already have the referral from my pcm...I just wanted to how everyones journey to getting approval went...And whether or not you had your surgery at an MTF or of post...Well hoping for a few responses thanks!!!!

Hi all, I've got a question that I would like anyone's input on. I am Tricare Prime and was banded in Mexico May 2007 with an Inamed band. I chose Mexico b/c I could not afford to pay what an American doc would charge me. Plus, I did my research and found a reputable doc in Mexico. At the time of my surgery, as we all know, Tricare was not covering this type of WLS. Soooooo my question is now, does anyone know if Tricare will cover my fills and/or maintenance with a civilian bariatric doc? Right now I am paying almost $600 for every fill (under fluoro). I am concerned though because now I am starting to have acid reflux and aspirations while I am sleeping and I have got to see my bariatric doc to get this problem addressed.

Thanks in advance for all of your suggestions!

You don't need a referral with standard right? I just researched a surgeon and went to him straight away. I'm 100+ overweight and have severe arthritis and I'm 29. I'm being banded 4-23, everything has gone through fine far, but I'm going to call Tricare today and just check to make sure they have everything and that it was approved.

I'm so thankful they don't require much, THANK GOD!

Correct, with Standard you don't need referrals. It's a good idea to make sure they got everything, as you do have to prove medical necessity. That's the great thing about Standard. Unfortunately for me, since I'm now collecting disability, I will be required to go on Medicare June 6th, so I want to make sure I get banded by then so I can drive 20 miles instead of 100.

Hi all, I've got a question that I would like anyone's input on. I am Tricare Prime and was banded in Mexico May 2007 with an Inamed band. I chose Mexico b/c I could not afford to pay what an American doc would charge me. Plus, I did my research and found a reputable doc in Mexico. At the time of my surgery, as we all know, Tricare was not covering this type of WLS.

Actually, it was covered in May of 2007 but, the change didn't get into the manual until recently. They said they are reimbursing for people who self payed after February of 2007. Hopefully, they will reimburse for surgeries in Mexico, so you should be able to get some money out of them!

Hi all,

I have Tricare prime in Europe. I went to see my Primary care Physician and asked for the procedure, he sent in the request that day, then Tricare in Germany approved me to go meet with the surgeon off post and then he said yes then he had to send it to germany and Tricare had to approve me again. All this took about a month and I was banded on the 20th of March. We have a nutritionist here on post that we can see. I loved it, it was so easy to get approved and there was no copay. Tricare just started covering the lap band Feb 1st 2008. Apparently I was the first spouse to get it here that was covered, so that was pretty cool.

Wow...I'm so jealous of all of you who have been banded so fast . I am *still* waiting to hear if Tricare will approve or not. I started this whole thing in December! We are getting ready to PCS in about, oh, TWO WEEKS!!!! My surgeon knows this and assured me he'd have me in for surgery well before our PCS date. Now I'm not so sure. :thumbs_up:

Just popping in with my woes...still glad to hear of all the approvals, though, and congrats:thumbup:

I have tricare standard and had my band done on jan 28th. I have lost 38 lbs so far. I have only had two fills which have not done any good but will get another one soon. I have tricare standard. I was approved the 14th of jan. I have so far only had to pay my doctors fee which was 245.00. I expect to pay 545.00 for the hospital and maybe a small percentage for fills. It took me two years of trying to get approved and then once the change came in less than two weeks as soon as I could get them to read the change. In fact I sent them a copy. I work out 5 days a week and is the main reason for my weight loss until I get some restriction.

Don

Why are you paying so much out of pocket? With Standard it's a 300 deductable, (for family) and then your cost shares which should be around 15% of each visit, granted you are going to someone who accepts assignment for tricare , are you no where near reaching your catast. cap? Between me and my DD's, we've met the cap for the year already, so I don't expect to pay ANYTHING out of pocket for my surgery 4-23, so I wonder about what you said?

If you look up the cost share it is 25% of the doctors fees and up to 545.00 of the hospital fees. You can find that sheet on line. I have met the deductable allready. This is just what you are required to pay.

Here is the web site. I am retired and have standard. TRICARE Cost Share

Don

Edited April 9, 200818 yr by dallman

I think it might be b/c you are retired, it's a bit diff. for beneficiaries of active duty, also if you go to a network provider, it's a 15% cost share, but you aren't limited to going to in-network, you'll just pay more out of pocket if you do.

My PCM is working on my referral I have already gone to the seminar, had an eval, done my psych eval but the last visit to my PCM I had a BMI of 37 since then ( over a yr ago ) I had a child ( six month ago ) and have gained my weight back and then some..I have a physcial schedule next week which will show my BMI at 40 but does anyone have any suggestions as to what I need after that to get approval??

Tricare requires that you be 100 lbs overweight and if not, then you must demonstrate that you have at least 1-2 co-mobidities, inlcuding hypertension, diabetes, sleep apnea, etc. This is from Tricare. The link won't work but I believe you can get to the manual via tricare.com.

Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online. A search for "morbid obesity" goes directly to the correct section.

My PCM is working on my referral I have already gone to the seminar, had an eval, done my psych eval but the last visit to my PCM I had a BMI of 37 since then ( over a yr ago ) I had a child ( six month ago ) and have gained my weight back and then some..I have a physcial schedule next week which will show my BMI at 40 but does anyone have any suggestions as to what I need after that to get approval??

How old is your psych eval? What kind of eval did you have (nutrition)? I am a bit confused, you have done everything that your surgeon would want, but don't have a referral to a surgeon yet? Is that what you are saying?

Once your referral goes through to see the surgeon for the initial consult, I would ask them before the appointment how current the psych eval needs to be (within a few weeks, a month) and if they need anything on a special form or just a memo (my surgeon needed a memo, psych said some surgeons have a special form). If it is within the required time line, call whoever did your psych eval and ask them to submit the memo or form to the surgeon. If everything is within their time line, they should be able to submit for surgery approval right away.

Hey all,

I am new to posting on this board but have been reading it for sometime now.

I have a problem and I wanted to see if anyone else has had this type of problem with Tricare. First some background info: I have TriCare standard, retired military with 30% diability so I receive most of my care thru the VA but they do not do the lap band. I am barely the 100 lbs overweight, Bmi 40.4, and have just received my CPAP machine for sleep apena. I had my first appt with surgeon on June 26, handed in all my paperwork including my first sleep apena test. I told him I had my second test on June 25th but didn't have results back. He said he'd send the request to TriCare without the second test results. On July 1st, I received my results and my CPAP machine. I immediately took the test to the dr's office which was put in my chart. On July 2nd, I received a letter in the mail from Tricare stating I was disapproved ( letter was dated June 30th ). The disapproval said I needed one of the co-morbid problems along with my 100 lbs overweight. Since I received my CPAP machine and have been confimed with sleep apena I didn't think I would of have a problem getting approved through TriCare. The Tricare letter didn't mention sleep apena as one of the co-morbids, it used the word narcolepsy. Do you think since I didn't have my second results in with the request that may be why I wasn't approved? I also have Tricuspid Valve Regrigitation from taking Redux and I am going in this month for an MRI on my left knee due to arthritus buildup and my knee giving out.

Any thoughts, recommendations would be great!:thumbup:

my psych eval is less than a week old and yes I have everything but the referral and my bloodwork. I even have a letter of appeal in case its denied but most people seem to have a pretty easy time getting approved I just wonder why mine is going to slowly and if there is something else that other people have done.

I was recently approved and am having mine done at a MTF. Once my PCM put the request in, I was called by the bariatric nurse less then a week later to get the ball rolling. I had to go in for a weigh in and information session where they went over tons of stuff. In order to have the surgery I have to weigh in every month, see the nutritionist for a class and then a 1 on 1 session, attend 3 seminars, 3 support group meetings, have a sleep study done, tons of labs, a psych eval, and a couple of other things I can't think of at the top of my head. What I was surprised about is 2 weeks before surgery I have to go on a high protein low carb diet and thats it. I am getting my surgery done at Womack on Fort Bragg and they really push the gastric bypass but I told the nurse that I didn't want that. The bariatric nurse told me that I have a few different things to do since I am being banded but she wouldn't tell me what it was specifically. I am just happy that I was approved so quickly and I think one of the main reasons is Tricare is now out of the picture since I am having mine done at a military hospital.

Edited July 7, 200818 yr by BjSkyGGEvan
spelling

So far I have paid :

$12 for my initial visit with my PCM

$12 for my initial visit with the Surgeon

$11 for the overnight stay at the Hospital

$12 for my first fill

$12 for my second fill

If you have Prime, why have you had to pay? Just curious, since I am Prime and have not had to pay anything and have been told I won't either.

My PCM has been the biggest hurdle in this whole procedure although it really hasn't been bad. I went to the PCM about it in December 2007, she said she would put a referral in after all my blood work came back. During that time, we discovered I have a form of leukemia. Fast forward, I have since gotten the go ahead from my oncologist and bone marrow transplant team and I go back to my PCM in late May 2008 for the referral. Consult with surgeon on June 3rd, nutritional eval and pysch eval less than a week later. Now we are just waiting on my PCM to update my referral to evaluate and treatment. 18 phone calls in one week and I come to find out that myself and another lady fell through the cracks in the transition from MTF to civilian surgeon since we are losing one of the military docs on base. Finally on June 27, I was approved by TRICARE (within one business of my PCM finally getting the referral straight). Pre-op appts on July 14 and surgery on July 22.

For once, I have been pleasantly surprised at TRICARE.