Has anyone been approved with one comorbidity? My BMI is 46.6 and when my insurance paperwork was submitted, they accidently only listed one comorbidity. The doctor's office said, "well, it's done now, so let's see what happens." What are the chances that this will actually be approved? :redface:

To be honest, I am not sure what comorbids were listed on my paperwork. I was at a 41.1 BMI and the only comorbid I know of is high blood pressure. The surgery was recommended by my oncologist though, since I have leukemia so maybe that played a part?!

Maybe. I guess I'll just have to see. I just keep hearing about the magical ~*2 comorbidities*~, so I'm nervous as all getup. <3

I don't know how many were listed on my paperwork either but I was approved a couple of days after it was submitted. You might be able to log onto the website and find out if you've been approved already.

You only need one that they list in the handbook

Does anyone know how long you have to have the co-morbidity for? I was denied by Tricare, but I'm preparing to appeal and just found out I have hypertension. So I should qualify now, but I'm just worried they might say I haven't had it long enough. I have the records from the dr. visit when I was diagnosed and it's noted that I was put on medication for hypertension. If anyone has any insight or experience I'd greatly appreciate it.

Where can you see the handbook?

The handbook says:

Obesity Treatment

TRICARE only covers morbid obesity surgery such as gastric bypass, gastric stapling and gastroplasty when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery
  

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
  
• Biliopancreatic bypass, gastric bubble or balloon, or gastric wrapping for the treatment of morbid obesity
  

Ugh. We'll see. Although I might fall under the 200% rule. 200% would be twice your weight, no?

Edited September 9, 200817 yr by tomatogirl
200%??

I am 5'7, weigh 240 and have diabetes mellitus and high blood pressure. I am a hoping!!!!!!!!!!!!!!!!!!!!!!!!!!!

Does anyone know how long you have to have the co-morbidity for? I was denied by Tricare, but I'm preparing to appeal and just found out I have hypertension. So I should qualify now, but I'm just worried they might say I haven't had it long enough. I have the records from the dr. visit when I was diagnosed and it's noted that I was put on medication for hypertension. If anyone has any insight or experience I'd greatly appreciate it.

I don't think there is a time stipulation on comorbidities.

I can't seem to get a straight answer from anyone at Tricare if there is a time stipulation on co-morbidities. Anyone else have any experience or ever gotten a straight answer from Tricare?

Not Yet but I should be submitting on the 29th and I will let you know.

Have you tried going to your local Tricare office and let them get that answer for you? Maybe seeing someone face to face will pin them down so you can get the answer.

Hey long, Did you use Tricare and if so was there any waiting period?

I have billed Tricare for ten years and it's also my insurance. Rule #1 with Tricare - YOU WILL NEVER GET A STRAIGHT ANSWER. Every time you speak to someone the answer will be different. My surgery paperwork was actually handled on base by one of the nurses whose job includes filing the packets for banding or bypass surgery. I actually had more problems getting the approval for spinal fusion surgery with three different doctors stating I needed the surgery right away. That took six months. The approval for the lap-band surgery? It was less than two months from the date of initial request to my surgery date (which was postponed - due to back problems.. ha ha on me..) I was shocked. Rule #2 - don't accept the answer from your doctor "what's done is done". Bull crap. It takes two minutes to call and amend your packet. Doctors do it all the time.

First up, did you go through a MTF or a private doctor? MTF is ten times faster than a private physician request. Next, did you make a list of all the diets you have tried over the last ten years? Even though Tricare doesn't request this, it helps. There is no time requirement for co-morbid symptoms. And don't let the wording fool you. If you have an immediate family member with any of these symptoms, tell you doctor to make sure they include that in the packet to Tricare! Having an immediate risk for these symptoms also supports your need for surgery. Ask your doctor if you are "pre" for any of the listed morbidities. Pre-diabetic, pre-hypertensive, etc. This all counts towards the co-morbidity symptoms. It's not the wording that the doc uses, it the coding. The diagnosis codes your doctor assigns to you is part of what helps determine if you get the surgery. "Pre" conditions are part of that code set. If you are just barely in the normal for sugar, you could be considered pre-diabetic. Also, find out in what order the doctor listed your diagnositic codes in. If the most severe was not in spot #1, your request can be denied.

It's all paperwork to the insurance companies - not real people. The fact that Tricare covers the lap-band surgery since 2007 was not in print until early 2008 - remember that. Some of the people who review your packet may not have the best or most current info. Make friends with the consult office on the closest base to you. They are the best people to push this through. If you have any questions, please feel free to email me at jokersjunk@yahoo.com Just don't let them tell you no!!!

Edited September 13, 200817 yr by radar626