Question:
TRICARE Criteria

I was wondering if anyone knew what the Tricare criteria is for gastric bypass surgery. My PCM did a referral and I am now waiting for that from Tricare to see a civilian doctor and I was wondering what the current criteria for Tricare is. Also when you see the surgeon, do they go by their criteria or the insurance criteria of saying if you qualify or not? Hope this made sense. Thanks in advance!    — ChrissyK (posted on October 12, 2006)

October 12, 2006
I had my rny in May of this year at that time the criteria was a bmi of 40 or more, at least 100lbs over weight or if your bmi is less than 40 you need to have co-morbidities. Well I was approved instantly by my surgeon and it took 1 day to get approved by tricare. I didnt have any co-morbidities but my bmi was 44 and as long you meet those requirements the surgeon I had will approve you. My surgeon didnt require any type of diet history or pysch evaluation. Hope this helps!!!God Bless you on your journey. You email me for more info if needed.
   — tia24tx

October 12, 2006
I was approved by Tricare in 1 day. Their critieria is to be at least 100 lbs overweight, with co-morbidities or 200% overweight (no comorbidities). Your best bet is to find a surgeon who specializes in WLS and is affiliated with a hospital recognized for bariatric excellence. They will be most experienced in doing the correct tests and sending a proper and convincing writeup to Tricare. Good luck!!
   — L. Nichols

October 12, 2006
Chrissy K.: We just came from Fort Polk, LA and now are in Missouri. Anyway, I just had my first appointment yesterday with my RNY surgeon. As far as Tricare: 1) You must be within the Morbidly Obesity range which is..."Morbid obesity is defined as having a Body Mass Index (BMI) of 40 or more. This equates to approximately 100 pounds more than ideal weight." You can check your BMI at: http://www.obesity.org/subs/fastfacts/morbidobesity.shtml 2) They like you to at least have one co-mobility (which means things like back pain, depression, arthritis, joint problems, GERD, acid reflux, sleep apnea, etc) I got my approval for seeing my surgeon about one week after my doctor sent in the paperwork to Tricare. Tricare only gives you a period of time that you can use that referral. It is about a 2 month period. One thing you might run into is that you may have to go to an informational seminar with your new doctor that is going to do the bypass. And then it may take some time for you to get into him/her. I ran into that I did have to go to the seminar because it was required, and I didn't get an appointment within Tricare's "window" they put on my referral. So, I had to have the referral reissued. In the time that I was getting that straight, I had to get a psychological clearance from Tricare (making sure that you know what is going to happen and how your life is going to change with eating, etc), and a referral from my PCM even though he did the referral. HOWEVER, every doctor is different. I would say your best route would be to call Tricare tomorrow, ask them who they refer to at Fort Polk, so that you can call that doctor and see what he/she requires for the initial visit. Sometimes you have to really plan things out. You have to play by their rules (Tricare and your gastric bypass surgeon). My first appointment, as I said earlier, was yesterday. I had all the referrals, test, etc. done already. My doctor put in for Tricare to approve for the surgery today. He said that he usually hears back within 4-5 days and never has had any problems getting someone approved that met the requirements above. As for the last question as to whether your surgeon will go by the criteria of Tricare, I would say contact the surgeon that Tricare uses. In Missouri, we only have three options for a surgeon, and the post usually uses one surgeon over another because of location closeness. Like I said earlier, it is really up to the surgeon on his criteria. The only thing Tricare really affects is that initial referral to your surgeon. After that referral to your surgeon, everything is pretty up to him and paper work! Please feel free to email me any time. We could be army wife buddies with gastric bypass...smile! ([email protected])
   — armywifepattee

October 12, 2006
Hi, I had my surgery in June of 2004. I had no problem getting approved by Tricare. I just had to have a psych and nutrition evaluation. My situation was alittle different because I was in Germany at the time. Now we are at Fort Drum and I see a bariatric surgeon in Syracuse. Hope this helped and if you want to chat or anyone else for that matter drop me a note ([email protected]) Tina
   — jtcaron

October 13, 2006
Tricare is no different than any other health insurance. To gain a valid authorization and obtain timely payment you must follow their criteria OR challenge their criteria successfully via the appeal/grievance proces. You also have to meet the physician's critera to have him/her provide the care. Lan
   — LanAtPtsMedicalClaimsAssist

October 13, 2006
Hi there! I am in process right now. My Dr. at first would not write a referral to tricare. So I switched, the second one was the same way. Basically I had to leave the country, lol.. I was in Japan then. Now I am in America and I explained to my doc that I think I would be a great candidate for this. He agreed and sent in a referral- but he did it over the computer. a week later I called to check te hstatus of it and found out that my Dr had PCS'd out and I am given a new dr. He had no problem with referring me to tricare. He told me what happens is his referral goes up for review in front of a panel of other drs before it gets sent to Tricare. 3 days later Tricare tells me I have 5 office visits with a surgeon of my choice in network and 3 hospital visits.
   — Ginah Clark

October 16, 2006
I had my surgery on Jan 4th of this year, at Walter Reed in DC, but I am now followed by a Civilian Dr in NC through TRICARE, and from what I understand, The Dr is who makes the call as to if you qualify for the bypass surgery. Your BMI and other health issues is what they use to make that call. If you warrent the surgery Tricare does cover it. and Does cover the follow up care for it as well, You will also need to see a PT person, a Nutritionist, a Psychiatrist, to determin if you are a good candidate for the surgery as well, and all of these are covered by Tricare as well. Then at 18 months they will cover a "tummy" tuck, for the extra skin. It was the best thing I've ever done, but It's something you really have to be ready for, it's not a diet, or something you can just stop one day. It's a life changing thing, and I wouldnt trade it for the world. I went from a 26/28 to a sz 8 in little under 10 months. and feel amazing! good luck and keep me posted on how things turn out for you!!
   — kneehigh70

October 19, 2006
I was approved last year for lapband with no problem. my BMI was 37.5 and I had one Co-morbidity high blood pressure. and I had only been diagnosed with HBP for one month before getting approved. I had my surgery at Walter Reed
   — H. MC

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