Tricare approval process?

Hey all.  I am a retired USMC dependent with Tricare Prime Insurance.  I live in Fred'burg area and just went to see my Primary Care Physician (civilian Dr) today to get the referral process rolling for the gastric bypass surgery.  I am worried that my Dr may not have taken down enough information to submit for approval and don't know how this process is supposed to work. I am not exactly 100lbs overweight, I am just under it by 10lbs, but my BMI and cholesterol are very high.  I told her I believe I have acid reflux and arthritis as well, but all she did was write all this down and said she'd send it off to the referral desk at Tricare.   Can anyone in the same boat as I am help me figure out if I am even on the right path here?   HELP!

I worked for TRICARE for 13 years and actually just left the TRICARE North office in Hampton a few months ago. If you are less than 100 pounds overweight then you of course have to have the qualifying co morbidities, they were also requesting for medical documentation of 6 months supervised weight loss program. I am not sure if anything has changed since I left a few months ago but I am willing to make some phone calls for you tomorrow to get additional info.

I went TRICARE Standard (also a retired USMC dependent in the F'burg area).  I am not sure how Prime compares, but I would suggest contacting TRICARE and having them answer your questions.  Best of luck -- if I can be of some help, let me know.  :)

Good am, I'm unable to answer your question but wanted to wish you the best with the approval process. Please keep us posted. Sharing your experiences will shed light on the ongoing processes many folks have and will face and EVERYONE'S input is a valuable tool. All best!

I am no help in this matter.  But I wish you the best in your journey!! I agree with others have said though, contact your insurer and find out their process.  I didn't do that the first time I went for the surgery and was suprised by what was requested.  Research as much as possible and ask them a ton of questions to make sure you get exactley what they want.  And don't be surprised or discouraged if they request further info.  That has happened to me and I am asking them where you want me to jump and I wll go.   Good luck!

I used Tricare Standard for my surgery.  Best decision I made....... Here is the info from their website

Gastric Bypass

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
• Is 200 percent or more over ideal weight for height and bone structure
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity

When I was treated, the criteria was a bit different, it was based on BMI and having 2 coomordities.  I had lower back problems, sciatic nerve problems, arthritist in my ankles and hips, depression, acid reflux, migraines.... My doc required info on my weightloss efforts.  Weigh****chers and stuff at home were included.  I went 5 years back on that, but there was no time limitation. There was no pre-approval.  My doc's office determined that I met the criteria, they scheduled the surgery and Tricare paid for it without question.  The doc just provided all of the paperwork showing that I met the criteria - along with their bill. Good luck!

I can help! :) I used Tri Care prime. My process was as follow's, which sounds like to me you are on the right path. I went to a PCP and they put in a referrel to the Portsmouth hospital ( where the bariatric surgeries are performed in my area ). All that she did was ask me about any medical conditions I had and checked my weight. Then I called the tri care line about 5 day's later and set an appointment once my referrel went through. The referrel is only to get you seen by the bariatric program nearest you. The first appointment was an opreigntation and they answer any questions you may have at all. They weigh you, and tell you if your weight, BMI or pre exitsing medical conditions ALONE qualify. Once that is established your put on a waiting list type thing, and during this time you will need to document 6 month attempted weight loss SUPERVISED which can be done through the nutritionist at your local military hospital. Once your time on the waiting list is up and you have your forms of documentation, they start with the medical testing, blood, ekg, and x ray, etc. It took me almost exactly a year because of some surgeons coming and going. But it gave me time to learn and feel very pre pared for my surgery esp with all the time I was on this web site!!! That was my journey through tri care prime, your's may be a lil different but I dont think your doctor was really supposed to do anymore then the minimal to get you seen at the bariatric clinic closest to you and then they do and explain the rest!!! Keep us posted and good luck! Brandi~

Here's my journey! Referral - my pcm is at Andrews AF base, so i got it from her, they sent it to walter reed first, walter reed said go civilian due to lack of room in their program (whew! that would have been a LONG ride home).  Seminar Consultation - with Dr. Victor Stelmack (Whom I am loving!) at Mary washington Tests- and lots of em More tests Labs - and insurance submittal.  They will need a 5 year weight history from your pcm - just weights and dates, also a letter of medical necessity, and if you have any co-morbs that you are being treated for, you should just go ahead and get clearance letters from those dr's.  The surgeon will send you for an EGD test for the acid reflux...and check to make sure you don't have any of the junk that can cause ulcers.  If you are getting RNY, they will need to treat any ulcer if there is one in your "old" stomach before surgery.  Approval in 3 business days!  i had a contingent approval, they wanted my lab results first, which they got and the same day they got them, they gave me full approval. Scheduled for my date, another nut class, hospital admin class, sign all the paperwork, another exam by the dr just making sure there's not hernias and to check out the placement of incisions and the port, he told me exactly where my incisions would be and where my port would be.  Pre-op diet, and surgery in 6 days!!!!! whoo hoo!  good luck!  Tricare wasn't too bad to deal with, my only problem was dealing with my pcm's changing three times during the process so getting tests ordered was a PAIN!

WOW, thanks for all the response!  I have called Tricare and wasn't given much more than what is already on the website . . . .actually all they did was refer me to the website for the information.   I was told that Tricare will go by the Metlife height/weight/frame chart.  I believe I might be small framed and according to the chart I looked at last night I am 100lbs overweight.  Odd, I have never wanted to be overweight by that much until now.  I'd rather not weigh this much at all, but for purpose for approval . . . .you understand what I mean.  Anyway, I  know what the Tricare website says, but I am just wondering are they flexible at all?  I mean, if I am 100lbs overweight but the only thing I have really documented is high cholesterol and a high BMI with complaints of back and joint pain will they approve it? That's what's really bothering me.  I can go back nearly 14 years with weightloss attempts!  I can probably show a yo yo pattern with my weight in my medical records alone!  I am just ready to be thinner and healthy!  Thanks for all the response friends!  I'll keep you informed on what I find out and when!