how tp get approved with tricare prime

deanna12345
on 3/6/11 4:06 pm
 hey can anyone help me, Does anyone know how to get approved from tricare for the lapband.....
Bubble S.
on 3/6/11 4:16 pm
As far as I know they are pretty fast as long as the paper work from the Dr's office is in order.

I have Blue Cross as my primary with Tricare Prime as secondary.  I have not had any trouble at all with Tricare paying their section of the bill.

Call Tricare and speak to a Rep.  I called them a couple of weeks ago and they were really helpful.

Good luck.
 Remember, if you want to be a 155 pound person, you have to EAT like one. 
  View more of my photos at ObesityHelp.com


LesleeInGlastonbury
on 3/6/11 4:29 pm - CT
 HI, I can "attempt" to guide you - I work for a health insurance company and was able to get my band approved.

First thing you need to find out is:
1) Does Tricare (which I believe is the gov't insurance for the military) even offer it as part of there product offerings?  If they don't offer it, it cannot get approved
2) Next, if Tricare offers it, does your Employer purchase that product?  If they didn't purchase that benefit, it cannot get approved.
3) You should call your Health Benefit Coordinator and ask this specifically "Do you offer coverage for medically required weight loss surgery".  Don't go into detail about the type of surgery - just ask that question exactly as I wrote.  If they say yes, ask them to provide you the guidelines for approval.


Now, lets assume that Tricare offers it and your employer purchased it.
1) There are general guidelines that must be met in order for Insurance to cover it.
2) Rule of thumb - your BMI must be at least 35 (just changed to 30, but not sure when that goes into effect) with at least 1 weight related co-morbidity (e.g. hbp, high cholesterol, diabetes, sleep apnea, etc).  If have no co-morbities, you BMI needs to be 40% or at least 100 overweight
3) Even tho you may meet these general requirements, there are several other steps you need to take before your surgeon submits for approval.  These steps take from 4 mos - 12 months!
4) Insurance companies want to see a "over weight history" with documented attempts at weight loss.  So if you dieted on and off and continued to see your doc every 3-6 months, your records will show weight fluctuations - this is perfect!
5) Next, your insurance guidelines will probably have you see a nutritionist for between 1 - 6 visits, with no more than 1 visit per month.
6) You will also need a Phych eval (which may require you to have further visits), Cardiologist workup, Upper GI series and a sleep apnea test (overnight at a sleep study facility)

Once all those tests are in, then the whole package is submitted for Insurance review.  If the paperwork is clear and all guidelines are fully documented, then you can sometimes get approval in a week.  Other times, items need clarification and can take a month or 2 of back and forth to get your decision.

So from the first time you meet the doctor until surgery day can be 1 year or more.  Mine, luckily was just under 6 months.

So do your homework now and don't be discouraged, all the tests and waiting time actually prepares you for the changes that will happen after surgery.  Remember, its a journey , not a race.

Life Begins Outside Your Comfort Zone
The "Band" isn't Around Your Head
Leslee in Connecticut
3/9/09 240 BMI 38% Body Fat 44% Size 18 Measurements 44-36-45
10/9/2010 139 BMI 22% Body Fat 12% Size 2/3 Measurements 35-27-34
Current 155 BMI 24% Body Fat 18% Size 4/5 Measurements 36-28-35
deanna12345
on 3/6/11 10:56 pm
 thank  you , your info was helpful
tmal66
on 3/6/11 4:34 pm - Aurora, CO
Lap Band on 05/24/10 with
Tricare does cover WLS.  My husband is retired AF.  First you need a referral from your PCP to a WLS surgeon.  You have to go thru a nutrition class, not covered, mine was about $200, you have to have a phsyc eval, should be covered.  Between you and your surgeon you decide on the surgery for you.  They submit the paperwork and then you wait.  It took 6 months from time submitted to surgery, partly because I had to appeal after they denied it. 
Good luck
deanna12345
on 3/6/11 10:55 pm
 Thank you  for your info, How did you appeal it?  I was denied...
tmal66
on 3/6/11 11:07 pm - Aurora, CO
Lap Band on 05/24/10 with
As the others have said, I got a letterr from my PCP, we also wrote a letter outlining concerns for my health in the future.  It took 2 months for the appeal process, then it was just set a date and here I am 9 months later down 50+ pounds and counting. 
deanna12345
on 3/6/11 11:14 pm
 so should i email my pcp and ask her to help me appeal or write a letter...  I hade to call the referral office and they told me it was denied....
tmal66
on 3/7/11 8:59 am - Aurora, CO
Lap Band on 05/24/10 with
I got a letter in the mail from Tricare, it gave all the appeal info.
-Mari-
on 3/6/11 4:52 pm
For me, My PCP sent in a referral for the lap-band, she knew all the "correct" things to fill out, so to speak. I had to be at least 100 lbs overweight and have one co-morbidity. Then the tricare office sent me the letter saying which Dr was a tricare provider and in 2 months I was banded. The specific weight loss surgeon in your area may require different things that are specific to them.
 Mari  Nothing tastes as good as being thin feels!
deanna12345
on 3/6/11 11:06 pm
 Im glad to heard about your out come.   my pcp gave me  a referral but it was denied. i guess she didnt say all the right things your pcp did...
ooo2bthin
on 3/6/11 5:50 pm
I have Tricare-Prime as well.  The first step is visiting your PCM and getting a referral.  Once your PCM gives you the referral the ball will start to roll.  Do you live near a base?  If you go to the bariatric department on base it moves faster.  However, I fell in a catch 22 my hospital is merging with another hospital and bariatric surgery has no priority.  We switched surgeons 3 times in 6 months and there were times when the surgeon was not performing surgery because they could not get the operating room.  If you go to a civilian surgeon you will need to see a nutritionist for 6 months.  Try to get started right away because if you go by March 31st, they will consider March your first month and that will reduce your time to 5 months.  The one positive aspect of getting surgery on base is each base is different and they may not require the 6 month nutrition classes.  The biggest negative was that I lived one hour and a half from the base and had to go back and forth for every doctor's appointment and every test.  With the civilian I did every test over in one morning---less than 2 hours.  What a waste of money (double testing, gas) and time.  Good luck and schedule that visit with your PCM right away.  If there is anything else that I can help you with please let me know. 
deanna12345
on 3/6/11 11:02 pm
 I live about 5 miles away from bass. I had a referral from my pcm, but it was denied.... 
ooo2bthin
on 3/7/11 4:52 am
Good morning, I am sorry I assumed you were over 100 lbs. and had a comorbidity.  Are you 100 lbs. over the recommended weight for your height?  Do you have a comorbidity such as high blood pressure, diabetes, sleep apnea something like that (the list is on the Tri-Care website)?  Do you snore?  If you snore get your doctor to order a sleep apnea study, which may prove that you have sleep apnea.  That with being 100 lbs. overweight would qualify you for surgery. 

As far as the denial, you have 30 days to appeal.  Have you received the denial letter?  If so, it states why you were denied.  Can you disprove the reason for denial?  If so, contact your doctor and have him/her write a letter stating why surgery may benefit you.  Also, you may want to contact your Tri-Care advocate.  Good luck to you. 
deanna12345
on 3/7/11 5:12 pm
 i didnt get a latter in the mail but i called the referral office and the lady said they denied me and i lefted if as that..... tomorrow im going to call the office back... 
Karsonsnana
on 8/13/11 4:18 pm
I have been reading about the Tricare approval process and was relieved to see you had stated sleep apnea qualified with Tricare as a co morbidity. I have looked on their web site and have talked to reps on the phone and none of them would tell me definitively that it was. :) Getting ready to have my surgeons visit and then my paperwork will be submitted for approval. Hopefully it will be approved and I will have my surgery in mid to late Sept.
Karebear79
on 3/7/11 6:25 pm
Lap Band on 05/24/11 with
What region are you in? I've heard Tricare's requirements are different in each region. I was just approved for the band through Tricare Prime last Thursday. I have no co-morbidities. Just 100lbs overweight. I did not have to do a 6 month doctor supervised diet or anything. I had to have a psych eval, a gallbladder ultrasound, a EGD, go to the seminar that the surgeon gives and get a letter from my PCM. That was all the surgeon required from me at my first appointment with her. I did all that. Would have been done within a month and a half of seeing her, but I had to postpone my EGD due to my husband's work schedule. (oh and my surgeon got married, so that knocked the month of October out..lol) So I had everything done mid December and then with the holiday's, nothing was happening until the new year. My doctor sent everything to insurance and they came back with needing a thyroid test (which I had done back in August so that was an easy thing to get taken care of, just a matter of faxing the results) and I also needed cardiac OR pulmonary clearance. I found this info out 1 day before I left for a cruise to the Bahamas. lol! So I had to wait a week to get that taken care of. I called as soon as I got back, got an appointment with my PCM and got in a week after that and January 31st I got an EKG. Well, my PCM waited almost 4 weeks to fax that over to my surgeon even though I discussed with her about how I've been delayed on getting this all taken care of so I can actually get the surgery due to my surgeon getting married (which I totally don't mind that, I was busy doing other things required in October anyway) and then having to postpone the EGD a month and then the holiday's. But yeah, then I was postponed another month cause she never faxed the results. But finally they faxed it, the surgeon got it last Monday and Thursday I was approved.

Definitely appeal the decision. You should get a letter in the mail of their decision and it will have all the appeal info in it.

~Karen~

    

6cc's in a 10cc band
deanna12345
on 3/8/11 4:32 am
 i live in the north region..... i had a appt. with my pcm for a band referral, i had blood work done thats all. whats a egd? 
deanna12345
on 3/8/11 7:36 pm
 my pcm gave my the referral and she told me to go the the referral office so i went and the aldy said ill call you in three day and if you dont hear from me from the to call her. I called her because i didnt hear from her and she said i was denied for the lapband .
Karebear79
on 3/8/11 5:37 am
Lap Band on 05/24/11 with
An EGD is when they put a scope down your throat and check out your stomach and such.

I am in the North Region too. And everything went pretty fast once they had everything they needed.

Are you having trouble getting the referral to a surgeon? I think I'm confused in understanding what Tricare is denying for you. I'm going to re-read your posts, but if I read them correctly you have just gone to the PCM for a referral to see a surgeon right? Cause it seems kinda weird that they would deny that. They usually always approve the referral to see a specialist. It's usually once the specialist submits for approval that there are insurance hick-ups.

~Karen~

    

6cc's in a 10cc band