Tricare Approval?

AZChick289 · June 24, 2008

I too am Tri Care and had my surgery last month.. I was 98 lbs over weight and 3 comorbities ..I was wondering if anyone knows if TriCare pays for the Fills ...

Thank-you in advance and God Speed to all those getting banded..

mphsmommy · June 24, 2008

I too have Tricare. I saw my PCM today for a referral and he said they go by your BMI. He said anything 40 and over is a candidate, and anything from 35 -40 with 3 comorbidities is a candidate.

mphsmommy · June 24, 2008

I'm not sure about the fills. I know here at Fort Bragg, they do the fills at Womack (the base hospital), so it's covered. I don't know what the case is if you are seeing a civialian doctor.

IntoLess · June 24, 2008

Tricare pays for the fills, why would they pay so much (or so little in Tricare's case) for the procedure and not pay for follow-up care? Someone posted the correct insurance codes for fills, I will have to look it up, but it is probably here on the insurance board.

To get the initial consult with the surgeon, Tricare goes by BMI, to get approval for surgery they go by pounds. The Tricare handbook is perfectly clear on that. Most PCMs think that since all other insurance companies go by BMI for surgery approval, Tricare does to, I know mine did, until I showed him the handbook.

IntoLess · June 24, 2008

I too have Tricare. I saw my PCM today for a referral and he said they go by your BMI. He said anything 40 and over is a candidate, and anything from 35 -40 with 3 comorbidities is a candidate.

Is this civilian or military doctor? A friend is having a problem at her doctor who is military, but I had no trouble with mine, who is civilian. I don't understand why doctors give different advice to people, and the Tricare handbook says something else. Tricare doesn't have to approve anything if done at an MTF, but the military doctors there have their own guidelines in place.

mphsmommy · June 25, 2008

My PCM is here on base and we have a Biariactric Center at the hospital here on base. I have only heard good things about all three surgeons in the Biaractric department here. Two of the surgeons are military and one is contracted through the government.

AZChick289 · June 25, 2008

Thank-you so much for the info...

LLMobley · June 14, 2009

Has anyone been approved by Tricare with being less than 100 lbs overweight?
I am about 85-90 lbs overweight with sleep Apnea and High blood pressure (therefore I have my 2 comorbitities).

Before I get started, I want to know if there is even a chance of getting approved.

Thanks!!

I don't want you to get hurt the way I am now. I got the referral jumped through all the hoops and tricare turned me down. I have sleep apnea which they no longer consider a co morbidity. This seems to have changed from May 27th when my PCM went on the internet and wrote the referral and June 3rd when I saw the surgeon. I am not at 100 pounds YET but the sleep apnea not being considered a co morbidity got my referral denied. So please make sure your doctor has checked and double checked. I do not think hypertension is listed anymore either. :blink:

cmedwards · June 15, 2009

Hypertension is still covered! WOO! HOO! You had me really scared!!!

If you have no comorbilities you will have to be 200% over your ideal weight. It's a shame but you may need to gain some weight. I pray that everything works out for you. Be optimistic, everything will work out.

LLMobley · June 15, 2009

Congratulations on your good news. I am happy for you. When are you scheduled for surgery?

kbrier2703 · November 3, 2010

i have tricare ins . i went to the seminar on saturday and had bmi of 33% and i am also on high blood pressure medication. i told the nurse that i fell like i am not going to get aproved and she said that you never know until you try. so i have my sleep study on thursday and my other lab test on sat. Is it worth it to do all this, have low hopes for approval.