Ahhh Tricare.

[kaitlynmarie93 0]

So as I have stated before I have tricare prime and was denied. We are currently working on my appeal and today I found out some bad/good news. It's bad news because I found out I have high cholesterol, it's good because it's concidered a comorbidity wich may help my case. I also have bad lower back pain that has been proved and documented to be frome my weight I have bad acid reflux discease and I have always been a hundred pounds or more over weight. We found out tricare required more information and a few other things. But does have more combordities help you get approved, I've heard it does but is this really true??? :laugh::confused::tt2:

[Princess losealot 0]

Hey, hang in there.

One thing that I learned getting the approval through tricare was this. The people in the benifits section are SO nice to talk to and helpful! Any time I called they gave me things I needed to know.

The problems associated with your weight are key to getting it moving along. I also got an aproval letter from my pcm stating he thought it was something I needed. I am RIGHT on the line of required weight for my hight, so I was worried. I just made sure I got my list of everything I needed and turned it ALL in. It seemed to do the trick. So get the other stuff added onto your request and see how it goes. But CALL THEM. They are realy nice people there.:laugh:

[tkee99516 1]

So as I have stated before I have tricare prime and was denied. We are currently working on my appeal and today I found out some bad/good news. It's bad news because I found out I have high cholesterol, it's good because it's concidered a comorbidity wich may help my case. I also have bad lower back pain that has been proved and documented to be frome my weight I have bad acid reflux discease and I have always been a hundred pounds or more over weight. We found out tricare required more information and a few other things. But does have more combordities help you get approved, I've heard it does but is this really true??? :laugh::confused::tt2:

I had high cholestrol & Tricare didn't consider it a co-morbidity (I was denied for Lap Band). I instead went to the 200% route & wrote an appeal letter (had MD sign it) stating I was "small bone", not "medium bone". That's when I was sucessful with my appeal. THEY TOOK ALL 60 DAYS OF THE APPEAL PROCESS TO DECIDE IN MY FAVOR. That's the rotten part....

[*barbara* 0]

I had high cholestrol & Tricare didn't consider it a co-morbidity (I was denied for Lap Band). I instead went to the 200% route & wrote an appeal letter (had MD sign it) stating I was "small bone", not "medium bone". That's when I was sucessful with my appeal. THEY TOOK ALL 60 DAYS OF THE APPEAL PROCESS TO DECIDE IN MY FAVOR. That's the rotten part....

Hello tkee99156 - can you explain the 200% route? I am curious if I could do the same although i don't know the criteria. You see, I don't have any co-morbities. My weight started at 250 lbs and I am 5' 4"...and according to a frame calculator i do have a small frame (some where under all this weight) and i do sometimes wear petite pants. According to the Met Life table a small frame should be 116-130 lbs (although I will be thrilled with 160).

[tkee99516 1]

Hello tkee99156 - can you explain the 200% route? I am curious if I could do the same although i don't know the criteria. You see, I don't have any co-morbities. My weight started at 250 lbs and I am 5' 4"...and according to a frame calculator i do have a small frame (some where under all this weight) and i do sometimes wear petite pants. According to the Met Life table a small frame should be 116-130 lbs (although I will be thrilled with 160).

Barbara - If you have the surgeon's office in their request for authorization for Lap band state that you are a small frame (documented by them along with your height & weight) you would meet Tricare's 200% requirement (see below) for 5'4" at 250lbs. You take 116 lbs X 2 (for 200%) = 232 or more pounds..... This is the route I took & it worked & got approved via appeal letter. The surgeon initially told Tricare I was a medium frame. After going back to my primary care MD & finding out I was a small frame, I then wrote the appeal letter with supporting note from primary care MD....

Here's Tricare's Policy (found in the TPM section entitled Surgery for Morbid Obesity, CH 4 Section 13.2):

Description:

Morbid Obesity means the body weight is 100 pounds over ideal weight for heith & bone structure, according to the mose current metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200 percent or more of ideal weight and bone structure.

POLICY:

A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one or the following conditions is met:

1. The patient is 100 pounds over the ideal weight for height & bone structure & has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints. (NOTICE NO HIGH CHOLESTEROL IS NOT IN THIS LIST)

2. The patient is 200 percent or more of the ideal weight for height & bone structure. An associated medical condition is NOT required for this category.

[*barbara* 0]

Barbara - If you have the surgeon's office in their request for authorization for Lap band state that you are a small frame (documented by them along with your height & weight) you would meet Tricare's 200% requirement (see below) for 5'4" at 250lbs. You take 116 lbs X 2 (for 200%) = 232 or more pounds..... This is the route I took & it worked & got approved via appeal letter. The surgeon initially told Tricare I was a medium frame. After going back to my primary care MD & finding out I was a small frame, I then wrote the appeal letter with supporting note from primary care MD....

Here's Tricare's Policy (found in the TPM section entitled Surgery for Morbid Obesity, CH 4 Section 13.2):

Description:

Morbid Obesity means the body weight is 100 pounds over ideal weight for heith & bone structure, according to the mose current metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200 percent or more of ideal weight and bone structure.

POLICY:

A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one or the following conditions is met:

1. The patient is 100 pounds over the ideal weight for height & bone structure & has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints. (NOTICE NO HIGH CHOLESTEROL IS NOT IN THIS LIST)

2. The patient is 200 percent or more of the ideal weight for height & bone structure. An associated medical condition is NOT required for this category.

Oh my god, thank YOU so much for letting me know this!!!!! This is the best news ! I decided to explore the possibility of getting surgery back in January and having been dragging my heals through the whole process because I have been in fear that I could be denied since I don't have any co-morbidities. I have read of Tricare's 200% policy before but never understood it and thought it was for people who were severely over weight. Finally the gray clouds have cleared and can almost see the sun!!!

Thanks again!

[tkee99516 1]

Oh my god, thank YOU so much for letting me know this!!!!! This is the best news ! I decided to explore the possibility of getting surgery back in January and having been dragging my heals through the whole process because I have been in fear that I could be denied since I don't have any co-morbidities. I have read of Tricare's 200% policy before but never understood it and thought it was for people who were severely over weight. Finally the gray clouds have cleared and can almost see the sun!!!

Thanks again!

Good luck to you!

Tammy

[mom2boys3 0]

So as I have stated before I have tricare prime and was denied. We are currently working on my appeal and today I found out some bad/good news. It's bad news because I found out I have high cholesterol, it's good because it's concidered a comorbidity wich may help my case. I also have bad lower back pain that has been proved and documented to be frome my weight I have bad acid reflux discease and I have always been a hundred pounds or more over weight. We found out tricare required more information and a few other things. But does have more combordities help you get approved, I've heard it does but is this really true??? :confused:

I hate dealing with insurance! I have tricare as well, and i think getting a letter from my pcm describing the finding of MRI of my lower back helped my case get approved. I know it is not on their "list" of co-mobilities but it worked for me. Im 5'11 and have a BMI of around 32. My back and high cholesterol were the only health issues we reported and it was approved.

Try getting a letter from the Dr about how he/she believes your back issues are related to your weight.

wishing you lots of luck!!

[*barbara* 0]

just a quick update on this thread - I have been approved for WLS! actually, i just changed my mind and decided to move forward with RNY instead of the lapband. But i just wanted to let you all know that I was approved through Tricare's 200% policy so if you don't understand it, I am pretty sure someone else explained it in this thread. Good luck to all!

Edited October 27, 2009 by *barbara*
forgot a word

[drm1123 0]

I'm still confused about it. The manual in 2002 stated that the 200% was based on both the lower and higher end of the met life chart weight for your height and frame. This didn't make sense to me because if you have to double the high end you more than double the low end. From this I understood that for a 5' 3" and a small frame my weight should be 248.

This provision disappeared in the 2008 manual. So what does it mean for me. Can someone tell me.... what exactly are they looking for? Do I have to double 111 (low), 124 (low) or somewhere in between. I don't want to take a chance of getting a denial since it takes longer to appeal. Can anyone who got approved via the 200% tell me how much they weighed and what frame when they got approved.

There is a proposed federal change coming up where tricare will catch up to other insurance companies and go by your bmi and also to cover the vertical sleeve, but I don't really see that happening this year. :thumbup: