TRICARE - PRIME

I AM SO CONFUSED... TRICARE DENIED ME BECAUSE THEIR REQUIREMENTS ARE THAT YOU HAVE TO BE 100 POUNDS OVERWEIGHT BEFORE THEY WILL EVEN LOOK AT THE REST OF YOUR PROBLEMS, AND I AM ONLY 90 POUNDS OVERWEIGHT.  GIVE ME A BREAK.  MY PCM IS FOR ME HAVING THE GASTRIC BYPASS(IT WAS EVEN HER IDEA).  SHE UNDERSTOOD THAT THE REQUIREMENTS ARE BY BMI AND NOT BY WEIGHT.  NOW THAT I HAVE DONE ALL MY PAPERWORK AND MY PSYCH EVAL. AND THEY DENY ME, SHE DOESN'T WANT TO EVEN TRY TO HELP ME APPEAL, BECAUSE SHE SAID THAT TRICARE WON'T LOOK AT MY PAPERWOR****IL I REACH THE 100 POUND MARK SO NO NEED TO APPEAL.  I JUST DON'T UNDERSTAND.  THE SCALES AT THE BASE WEIGH ME AT 6 POUNDS MORE THAN MY SURGEONS OFFICE AND EVEN THOUGH MY BMI IS 43 IT DOESN'T MATTER.  I AM 4 FT 11 IN AND I WEIGH 206.  I HAVE HAD KNEE SURGERY AND I HAVE LEGG AND CALVE PERTHESE DISEASE.  ( I DISEASE IN WHERE THE BONE OF THE HIP JOINT DIES AS A CHILD AND CAUSES SEVERE PAIN AND ARTHRITIS).  I JUST DON'T KNOW WHAT TO DO. CAN ANY ONE HELP ME?  THANK YOU, LAYLA

If you're 4'11" and 206 pounds then you are 100 pounds over weight.  Each chart is different, but http://www.halls.md/ideal-weight/met.htm has the starting ideal weight for your height range at 103.  In addition, a BMI over 40 usually suggests that you are at least 100 pounds overweight.  You can appeal this denial.  You can gather all of the documentation and write a letter in your defense.  Your surgeon may even sign the letter if you do all of the work.  Good luck to you.

Tricare goes by the Metropolitan Life Tables for IBW. According to that here http://www.bcbst.com/MPManual/HW.htm to be over 100 lbs you need to be 211 lbs. So yeah, about 5 lbs too light. I know it stinks. All I can say (and I've read on this website people doing it) if you gain some weight go back to your PCM and do another weigh in. Then re-submit the new weight at 211 or over. You don't need to re-do all the other tests.  Another thought, unless your PCM specifies, they go by medium built (that is the 211 number). If you are small framed you only need to be 203 lbs. If you are small framed have your PCM re-submit with that info. Sorry I know this must be so frustrating for you (((HUGS)))

I was denied this week because when my paperwork was gathered in February I was 2 pounds short of meeting the 200% of the ideal weight and not having to have any comorbidities.  Because I was under that range (by 2 frickin pounds!!!), they classified me as trying to have this done being 100 pounds overweight with comorbidities, and I have none so i was denied.  I am appealing this surgery becasue I have gained about 10 pounds since then, so there shouldnt be any trouble I don't think this time.  To me it is worth gaining a few to have this done, because I knew eventually I would gain it anyway.  I think you should try to do the same, 6 pounds is too close to turn away now.