Anybody have TriCare?

My hubby is in the military and we have TriCare Prime. I have an appt with my PCM on July 2nd to discuss getting a referral to surgeon that performs LapBand procedures. If you have TriCare I have many questions. Was it approved? If so was the approval process lengthy? Were you forced to do a 6 mo planned diet before they went ahead and allowed the surgery? I keep reading things from other ppl and what their ins. companies required them to do before the surgery. My PCM's nurse said that quite a few women have been referred for lap band surgery but she wasn't sure if most of them were approved for surgery. I really want this and Im just so nervous TriCare will say no.  Any advice on what I should expect would be so appreciated!!! TIA, Ryanne

Hi Ryanne! According to Tricare's current policy they don't cover the LapBand. I've seen people say they were denied it because Tricare deems it too experimental. Though, and I'm sorry I don't remember who, I read a profile of a military spouse that got the LapBand at a military training facility (MTF). Of course you don't deal with Tricare going through the MTF. I'm not sure what region you are in, I'm in TriWest region, but I was able to go the their website and did a site search typing in Gastric Bypass or weight loss surgery. Good luck!

Hey there Ryanne, I too have tricare prime, My MTF is NAS JAX navy hosp but my surgeon is a civilian doctor. I just had my consult yesterday and was informed the reason why Tricare does not cover Lapband is because of the associated risks and low success rate compared to RNY. Basically saying Tricare prefers RNY over Lapband. Good Luck, Tamara

Ya know that just seems so weird. RNY has so much more risk! It doesn't seem to make any sense to me. Grrrrr... I have read other ppl's pages and have said that tricare paid for their banding and others that said no it wasnt covered. But since you went recently I'll take your word for it. Im still going to my consult on the 2nd. Since banding is not covered are you pursuing a different surgery that is covered?  Ryanne

Ryanne, As far as I know, Tricare does not cover the LapBand procedure because it is considered to be experimental.  If you go through a MTF, you may be able to have the lapband as you won't have to get approval from Tricare, however the wait lists are pretty long, at least from what I've heard. I know you didn't ask for any personal opinions regarding the risks involved with lap band vs. rny, but I'm going to offer you mine anyway       I personally believe the lapband has more risks than gastric bypass.  With lapband, you have a foreign object in your body.  That foreign object can erode, grow into the surrounding tissue, or slip...all of which would require removal of said foreign object.  The "port" which is placed under the skin can malfunction, not to mention the inconvenience of having to get fills every few months.  Also, you can cheat the lapband.  Those were my reasons for choosing the gastric bypass.  With gastric bypass, there's no foreign objects in your body, your stomach and intestines are simply re-shaped.  Once you heal from the surgery, there's really no worries as long as you follow your doctor's rules.  It is reversible, despite what some people think.  It is a permanent tool to help you lose weight and keep it off.  To me, the lapband just seemed more risky due to the fact that it is a foreign object that may not hold up over time. That having been said, I wouldn't dream of trying to talk you or anybody else out of lapband and into rny.  It is a personal decision and one you should make with your heart.  I just wanted to point out the differences in risk...please don't flame me! 

Im soo not gonna flame you!! You are exactly right to be honest. You said some things here that I never heard of .. You never hear of the bad. I also did'nt know gastric was reversible! Im still not 100% Im going to do the lapband.  A friend of mine told me about the MTF thing. It sounds like it may be a real pain in the ass and not to mention the waiting list. I didn't realize you had to go on a waiting list with MTF. This is def. something hubby and I are going to have to talk about.  I never even heard of the fills til today. That sort of turned me off to be honest. Seems like a pain in the ass.  Im glad you brought to light that gastric is reversible. I really am.. something to ponder!! Thank you for your insight!

In the letter I received from tricare it states:  gastric bypass, gastric stapling or gastroplasty is covered when one of the following conditions is met:  1.  The patient is 100 poinds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome( and other sever respiraatory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.  2. the patient is 200% or more of the ideal weight or height and bone structure.  A associated medical condition is not required for this category.  I can tell you that if you don't meet these requirements exactly you will not be approved.  Also... I attended my surgeons seminar and the stats on the lap band versus the rny are staggering.  He put it this way,  you have a 5'6" 300lb. woman,  she has the rny and 18 months later she is down to 170 pounds.  If she has the lap band it takes her 3 years to get down to 200 pounds and that 30-50% of people who have the lap band never loose 10lbs.  Also  4 years after having the lap band they have gained 15 pounds.  I just thought that you should have this information, use it how you would like.  Hugs,  Layla

Thanks for the info! The girls that I know that are getting RNY through TriCare said that they only needed to be 40 over their BMI and they didn't have any other major complications due to their weight. I have some issues so I think Im covered. I don't have anything major but I am borderline diabetic, I get knee joint paint and feet joint pain in the AM, i sometimes wake up gasping for breath.. nothing major just every once in a blue.. I quit smoking a week ago so that is helping.. I have really really bad acid reflux due to my weight, on meds for that.. so I think Im in the clear. Im staying optimistic theyd do it. Does anybody know of a good Dr in southern Delaware or in the Dover area?

Congrats on quiting smoking    You just added years to your life.  I had really bad acid reflux too and took medication for it.  RNY cured my acid reflux and I no longer need the meds.  I don't know your stats, but here are mine when I was approved for surgery:  234lbs. at 5' 3" with a BMI of 42, no co-morbidities.  I was approved based on pain in my weight bearing joints...knees, hips, and ankles.  Tricare did not ask for documentation on this, they took my word and approved me. Good luck to you!  Let me know how it all turns out.

I just found out that the table tricare uses is the 1999 Metropolitian height and weight tables for men and women.  I called tricare and asked them to find out just what table they do use and they called me back within 15 minutes.(CAN YOU BELIEVE IT?!)    Anyway... they said that frame size does matter and if you do not put that in your paperwork they automatically put it in medium frame size.  although it doesn't state how to determine your frame size but my surgeons nurse said that they had asked her once before to measure someones wrist to find out their frame size.  she did a search online and found a  chart called clark state weight chart and it gives the guidelines for the frame sizes and how to measure them. If this info doesn't help me then I hope it helps someone else.