Now im worried

jeremiahsmommy · May 17, 2008

My WLS office sent my lap band in for approval with Tri-care prime. Some people are saying they got approved right away and some people are saying it is impossible to get approved for lap band with tri-care. My nutricianist said being 5'4, 273 lbs. with no co-morbidity i should get approved but reading some of the resposes on Tri-care is a little discouraging. Hopefully things will go well.

faithmd · May 17, 2008

Fingers crossed for you!

Often this is the issue: you and I may both have Tricare Prime, but our policies would likely NOT be the same. Different employers have the option when purchasing policies to add or remove various riders. One of those riders is for weight loss surgery. It is more expensive for an employer to pay for that rider.

Also, with large insurance companies, there may be different people reviewing requests for WLS, some (we are all human) may be more strict about requirements than others or may think your documentation is adequate while the next reviewer may not.

Unless your policy specifically has an exclusion to WLS, you can always appeal. Many folks have to. I did and it's nervewracking (I do not have Tricare), but I was approved on my second try.

Good luck!!!

westbrookdc · May 17, 2008

:thumbup:My request went in on wednesday the 14th and was approved friday the 16th. I have tricare prime. In fact, I just saw that it was pending yesterday at noon. I checked this morning and it was approved. Guess it's time to schedule the operation.

IntoLess · May 17, 2008

Tricare Prime is the same no matter where you are....Here is your problem, Tricare requires you be 100 lbs over weight (which you are) AND have two comorbids. OR be 200 lbs overweight and NO comorbids. I have spoke with people who have no comorbids and be 100 lbs over and get approved, BUT it is very rare. My problem is I currently have one comorbid, but that depends on my blood work because I think I am diabetic (swelling, tingling in hands, always thirsty, etc). If they take my HBP diagnosis from a couple of years ago I am good to go. We shall see.

I wish you luck. Don't hesitate to call Tricare, they have been fairly good to me when I call. Ask them what you have to do to qualify for the surgery. Then ask if there are exceptions to the comorbid rule. I honestly think it depends on the person reviewing your case, I hope you get one in a great mood!

Stay_Tuned · May 17, 2008

I would guess and say you will be approved... IF you go by the metropolitan chart... and go by medium frame.. you are like 3 pounds shy IF you use the highest weight for 5' 4" in the medium frame.... which is 138 times that by 200%and you get 276.....

I will keep positive thoughts for you.. Keep us posted!!!

This is the chart they use

Met life ideal height weight tables references

gina s. · May 22, 2008

I wouldn't think you'd have a problem getting approved.....I'm 5'7.5'', weigh 243, and have high blood sugar as my co-morbidity and I got approved by Tricare Prime. Good luck and let us know how it goes!

Dr. Ramos Bandster- Leah · May 2, 2009

If I were to add up all of the weight I have lost and gained...And all of the money I have spent getting HEALTHY.. I would have paid the the lap band 3 times over!

There so many going thru such a battle to get some insurance help. Like being in this state isnt hard enough! I ended up being private pay. Luckly I have for the Best Doctor in the world! He is sooo affordable!

I was having trouble Getting my surgery and financing also. But I found an awsome Dr. and my lapband only cost 5500. my surgery date is 5/19/09. Email me if you need and awesome Dr. for pivate pay. experiance.success.leah@gmail.com

we bandsters have to stick together!

PolarBZ · May 5, 2009

My wife just had her surgery today (5-4-09). She was fully covered by Tricare Prime (Remote), but it was not an easy task to get there. After the request was submitted by the surgeon, Tricare called and said she would only be covered under the "Point of Service" plan (50% covered) because she didn't have a referral. But, we DID have a referral from her original doctor.

So, she argued with them, resubmitted the referral and was approved, then disapproved by a higher supervisor. Finally after a rough pre-operation week of liquid diet coupled with Tricare stress, she finally got the head supervisor to sign off on it - everything except the only pre-op doctor's visit. We decided not to argue that piece ($200 after insurance) in order to not jeopardize the rest of the approval ($20k+).

Tricare is good insurance - once you figure out the bureaucracy.

My wife was covered under the 100lbs over and two co-morbids.