Question:
Has anyone ever been told they don't weigh enough to have the surgery?
My weight is not quite 5'4 and today I weigh 236. My BMI is listed at 42, but I have heard 238# is the "cutoff" weight. My insurance is Tricare Prime. Has anyone ever had to Gain weight prior to surgery? Tomorrow I could weigh 5# more with water weight. I'm open to any suggestions or advice. Thanks in advance. Victoria :) — perezrdh (posted on February 4, 2001)
February 4, 2001
If your BMI is 40 or above, there is no reason that you should be rejected
for surgery. I would be very surprised if any doctor said you weren't
heavy enough. Of course insurance companies can be more difficult. Some
insurance companies don't go by BMI. Instead they say you have to be
double your ideal weight. I think they just do that to make it harder to
get approved. If you ask other people who have your same insurance, you
can find out exactly what criteria your insurance company uses. And if you
find out that two pounds is the only thing holding you back, just drink a
big glass of water before you go to get weighed!
— Lynn K.
February 4, 2001
Victoria,
Hello. I am TriCare too. I am Standard so things work a little differently
for me. Are you near or on a base? If so, then you have to go through the
doctors there. If not, and you are using Prime in a remote location, then
it is like an HMO and you have to follow their rules (I guess). NOW as far
as Tricare is concerned, there are two ways to qualify for this surgery 1.
100 pounds over weight (according to the latest Met Life Insurance
height/weight chart, which is on line) and having at least one co-morbidity
OR 2. you have to be 200% over the ideal weight with NO co-morbidities. I
gained 15 pounds to qualify for the surgery (email me) and I was approved
in two days. BUT like I said you are Prime and I am Standard (I can walk
into any doctor that TriCare says is in the "network" and he
sends a letter of medical necessity and that is all). Here is a great web
page to be able to print out the TriCare requirements and take them with
you to your doctor!! I had to be at least double my ideal weight (at 5'
7" I am to weigh 130). I was told by another place that I had to weigh
double 140 (they used their own figures I guess, BUT that doesn't matter,
ALL that matters is what TriCare goes by), so I gained 15 pounds (cause I
only weighed in at 267 and I needed to be 280 according to this other
place). Well needless to say, I over qualified!!! I have taken off the 15
pounds plus an extra 5 while waiting for the surgery (which is this Friday,
the 9th). Please email me, as I feel like I can help!! [email protected]
Here is that web page for TriCare requirements!! Hugs Jann
http://www.infoseek.comwww.hotmail.com
— paschool
February 4, 2001
Victoria,
I also am Tricare Prime. I had to jump through a lot of hurdles. It looks
like you are getting good advice. Tricare has there own special rules. If
you qualify by there standards you should have no problem. I have surgery
on the 12th. I would be happy to answer any questions since we are both
Prime. A lot depends on what base you are at. My email is
[email protected]
— Trina L.
February 4, 2001
I am sorry, I forgot to mention when I started this whole process with
Tricare I weighed 230. I am 5'3". I qualified. You should have no
problem with the weight requirement part of it. Sorry I forgot to mention
that the first time. If you do have a problem with the weight requirement
I guess you will have to decide whether or not you want to gain a few
pounds to qualify. Go to the weight table to make sure. Have you already
seen your PCM? If not, I suggest you have all your ducks in a row before
you ask Tricare for approval. Email me if I can be of help.
— Trina L.
February 4, 2001
Hi Victoria! I, too, am Tricare Prime and 5'4". According to the Met
Life tables my ideal weight is 135, which means that at 269 (my current
weight) I am 1 lb. shy of 200% of my ideal body weight. BUT the other way
to meet Tricare's requirement for surgery is to be 100 lbs. over ideal body
weight with a co-morbidity. These can be: arthritis (ask your PCM if
joint pain such as knee discomfort, leg pain, back pain etc. can be
qualified as arthritis. Often it is not diagnosed as such but MAY be
considered arthritis.); GastroEsophagal Reflux Disease (GERD) which MANY
obese patients have; Asthma; Diabetes; Heart problems, including high blood
pressure; and many many other illnesses that are not specifically written
in the Tricare manual. Have your PCM write down EVERYTHING that may
qualify as a co-morbidity and submit it to the Tricare Health Care Finders.
Keep this in mind: the ONLY people who can deny you this surgery is the
FINAL decision board at Tricare headquarters. Do not settle for a NO from
your Primary Care Physician or the Health Care Finder. Take it ALL THE WAY
TO THE TOP. GOOD LUCK!!
— Laura B.
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