help with tricare prime??

I was just wondering, does tricare prime only require a BMI of 40 in order to approve or do they need to have the 6 month diet and other tests that are required by other insurance co.? My Insurance corrdinator sent in my papers on Monday of this week and my case is now pending with tricare. I asked why it was pending and the person said that they didnt know. SO that is why i am wondering if maybe they need additional information from my surgeon?

Hi Cristy, I also have Tricare Prime and received my call on Valentines Day that I was approved for surgery.  My BMI is 42 and I do have Hypertension.  So my PCM at CAFB, NM sent my referral in for a bariatric surgeon on Friday 2/2/07.  I received a call on that Monday that they were sending me to Dr. Applebaum's office in El Paso, Tx.  It took 3 days for Dr. Applebaum's office to get my medical records from the base (they needed my records before they would schedule any appointments), they reviewed my records at Dr. Applebaum's office and submitted all the neccessary paperwork to Tricare for Lap Rny.  They called me on 2/14/07 to say I was approved for the surgery and to schedule all the neccessary appointments.  I have my psych eval, nutrition and education appointment of 3/28/07 and my consultation with the doctor on 3/29/07.  Since the office is more than 100 miles from my PCMs office Tricare will reimburse travel expenses as well.  So it was not difficult at all getting the approval done.  Dr. Applebaum's office was on top of everything.  While I wait for March to roll around.  I've done alot of research on his practice and I've heard alot of wonderful things about him.  I hope this helps a little and if you have to keep calling Tricare so that your paperwork don't "fall" between the cracks.  I say GO FOR IT!  I'm sure they would have taken longer than 3 days to fax my medical records if I hadn't called them EVERY DAY until they did. Letishia

Cristy, Sorry I forgot to add I was NOT required to do a 6 month diet.  So the only test I will do are the ones that Dr. Applebaum requires. Letishia

I have Tricare Prime North and I was denied a few days ago.  I have a bmi of 40 and I dont have any comorbs only that I have borderline sleep apnea.  I was so upset.  I did 6 months of test that they required and they still denied me.  I am going to switch to my insurance, Aetna.  They only require a bmi over 40 and no comorbs.  I have alredy done all the testing that is required so I am going to be all set with that.  They say that I have to do a 6 month diet or the testing that I have already done.  I have talked to so many people with tricare that have got the surgery with just the bmi, I really don't know why it matters that I am in the north region.  Oh well, good luck!!!

This is what my Tricare Beneficiary Handbook says: Gastric Bypass- To be covered, you must be 100 pounds over ideal body weight and have a co-morbidity or 200 percent of ideal body weight with no co-morbidity. I had a BMI of 42 with no documented or diagnosed co-morbidities, but I was approved due to pain in my weight bearing joints.  My surgeon's nurse deals with Tricare on a regular basis, so the Tricare person worked with both of us to get me approved.  I was approved in less than 24 hrs.  I advise you to call Tricare, every day if you have to, and find out why your case is pending.  If you don't get a straight answer from the first person you talk to, call again.  Sometimes I have to call up to 3 or4 times before I get to talk to someone who knows what they're doing.  What region are you in and are you still active? Hope this helps you.  Feel free to ask any further questions you may have.  You can PM me if you want.