What TriCare Requires for Approval

[YngGram 73]

I just got this from the insurance coordinator at a surgeons office:

The criteria requirements are as follows:

1. a 6 month structured weight loss program

2. Lab results from: Hpylori, TSH level

3. Pulmonary clearance

4. Cardiac clearance

5. Psychological evaluation

6. Nutritional evaluation

My question finally was answered and I am very disappointed to know that I have so much time in front of me before I can hope for surgery.:smile:

[Maggies 0]

Tricare does not require the 6 month weight program, unless they changed in the last day or so. I was approved for surgery on Oct. 17, and I did not have to have it. Call Tricare and talk to them. Good luck on your journey. Maggies:shades_smile:

[Doxie 2]

This is what Tricare requires:

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only 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 (takedown)
  

I don't know where she got her information. My surgeon requires the nutrition and psych eval but not a 6 mth diet and the other things are general pre-op requirements....hope this helps.

http://tricare.mil/mybenefit/jsp/Medical/IsItCovered.do?kw=Gastric+Bypass&x=12&y=15

[Rdy4ANewLife 3]

Wow, Im going through Tricare as well and all I have to do is get a Psych Eval done and the doc said im good to go. I guess its different in each region. Im with TriWest, since im in Arizona. I wish you the best of luck with your journey!!

[annjones 3]

I have Tricare insurance. I started looking into Lapband in Aprilish 08. Had my first Dietician apt in June. A couple psy apts. (man those Personality Tests are a hoot) and just this week I received notice that I was approved through Tricare and my surgery should be the end of Decemberish.

I think the schedule you have may sound nastier than it is. My advise is to make sure you have all your paperwork and all YOUR duckies lined up. That way it is all on the docs and the ins.

Good luck!

[YngGram 73]

I am in the north region, where are you. I spoke with two surgeons offices and both told me the same. One was nice enough to pass it on to the insurance coordinator who emailed me the info that I pasted into my post.

[MrsMAJL 0]

I also have Tricare (Prime) and I didn't have to do anything but get a referral from my PCP. After that, I made my appt. for my initial consult On March 4th of this year. I got my approval for surgery from Tricare 6 days later. I had surgery on April 18th of this year.

I am not sure if they have changed the requirements since I've had surgery, but I was 100+ pounds overweight and had bad knees.

[RestlessMonkey 7]

Your best bet is to contract Tricare. I agree with the others that I've NEVER heard of tricare requiring 6 mos diet, h. pylorii test, etc. I have Tricare standard and was approved in 2 days because of my initial high BMI. Tricare is the best source of info on tricare, not surgeons, no matter how nice or well-meaning they may be! :smile:

[kerimezz77 0]

I didn't have to do the 6 month diet. I did the psych eval, Dietician, pulmonary, and details of my past dieting, and got the approval in 4 days maybe!

Good luck

Keri

[YngGram 73]

Hi All:wink_smile:

I choose to fight the no real answer game and below are the results. It Updates what I posted last week.

Marla,

I have communicated with the insurance company from the customer service, to Medical Management to the Policy Divison TMA West a Mr. Bob Bassey. I have been assured that TriCare DOES NOT REQUIRE A STRUCTURED WEIGHT LOSS PROGRAM!

This seems to be from the surgeron, Ruth has given me some info that should meet the requirement, but I will not use your service for that. Once I am into my program I will follow up on the next steps for surgery with your office. I do wish you and the team had been more honest about who was making the requirement.

Jardenia

Their Response:

Because of your (and other Tricare Standard patients)concerns about criteria requirements for Tricare Standard, I've called and spoken with our Healthnet representative. After a lengthy conversation she states there has been a re-review, and although they recommend the 6 month WL program, clearances etc. we(Dr. Halmi) are no longer required to make our patients comply. If they (Tricare Standard patients) so choose they may proceed as desired with the minimum of having a BMI of 40 with the knowledge that medical necessity is determined at the time the claim is review.

We can schedule your surgery at any time, providing that you are willing to sign a waiver that states you are aware there is no pre-certification

process and may/may not be responsible for your bill.

At no time are we dishonest with our patients as that is certainly not good business practice. :biggrin:

I LOVE TO WIN!!!!!

[JamieNP 20]

When I had contacted Tricare, all they gave me was the 100 lb or 200% thing. But my surgeon's office said that they require certain tests. Psy eval and EGD plus the blood work. I also had to have the gall bladder scan and nutrition class for my surgeon's office. Your surgeon may require the supervised diet.

[LAYTONBI 0]

I am going through tricare as well. I didnt have to do any of that. Actually the whole process for begaining to today when I was approved took 3 weeks. I have my surgery in monday the 3rd. No classes except for the nutrition class which they r going to let me take after the surgery. I weigh 225. I dont have any co-mor. I didnt have a sleep test or anything. No high blood pressure. Nothing! I just saw my PCM got a referal saw the surgon last week and this week I am approved.:biggrin: