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!