Tricare Prime bypass approval
I just saw my civilian PCM and said I want to see if I qualify for the surgery and she wrote down my height, weight, BMI, cholesterol and possible acid reflux and arthritis, but that's it. Is tricare going to laugh at this and send back a big fat NO for surgery referral? And do you get the initial referral to a surgeon and THEN get a final approval after the surgeon does the work up on you with the psychiatric and all the other evaluations they do prior? My problem is I am only 90lbs overweight, with a BMI of 42.8 and cholesterol in the mid 200's . . . those are the only things that are documented in my medical records. . . . I don't want to have to diet for 6 months with a Dr's supervision when I have already tried to lose the weight over the last 10-13 years just to gain it all back again . . . . . any information will help!
Lee, First off, Hello and welcome. Here are what I hope are answers to some of your questions. First off, Tricare does not require a 6 month diet. So, the only diet you may have to do is pre op to shrink the liver and that is determined by your surgeon. Here is how it works. 1. PCM sends referral to Tricare for authorization. Tricare will approve or deny the request. If they approve, they will send you to an in Network provider. 2. Tricare's requirements Gastric Bypass (Surgery for morbid obesity) – Limited Benefit – Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty may be covered when one of the following conditions are met (view Hospitalization Costs): The patient is 100 pounds over the ideal weight for height and bone structure and has an associated medical condition, such as diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints. The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions. (this is by using the metropolitian weight table.) Laparoscopic adjustable gastric banding is covered, effective February 1, 2007. The following are not covered: Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633). Gastric bubble or balloon Gastric wrapping/open gastric banding (CPT code 43843) Unlisted CPT codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum). 3. Once you have your consult, there will be some tests that will need to be done. Prior to consult, you can have your PCM do these referrals and get ahead of the game. Psyc Eval Pulmonologist - they may need to do a sleep study You will need a full work up of labs from A to Z (when I get this done is about 7 tubes of blood) - Also make sure that you get a Hypolori test (this rules out peptic ulcers) Nutritionist consult. - if you are near a military medical facility, they sometimes have them available, just need referral from PCM. The bad news is that I do not think Tricare will pay for this. Your PCM will need to write a letter of medical necessity, and you will also need an EKG done and signed off on by the doctor. The above items is what exactly is requested by Tricare but, the surgeon my have other tests that need to be done. Oh and one last note, I would get a full exam to document all aches pains and illnesses you may have to help in your quest. Good luck.
I have to agree with the above poster, but this may put your mind at ease. Just keep in mind that just b/c it happened for me doesn't guarantee that it will happen for you. I had a BMI of 41, which Tricare doesn't give a crap about they don't look at your BMI and I also have Reflux, which Tricare does give a crap about. I was denied on March 3rd b/c the results from my Upper GI weren't sent to Tricare w/ all my other info. Whenever my Dr.'s office filled my appeal they included the results from my Upper GI and I was approved within 10 days. Best of Luck to you!!!