Had 1st Consult, time to gather info for approval from Tricare

I had my first consult with a civilian doc yesterday and then his office gave me the list of required documentation, etc to gather together to submit to Tricare for approval of the surgery. I started making calls, etc today and was told by a Tricare rep who consulted with a RN that I do not need everything on this list that was provided to me by my surgeon's office. My surgeon's office has a lot of experience dealing with Tricare Prime (what I have) and they said they have always used this list of requirements. Here is a brief description of what the list contains: 1. bmi must be 35 or above (mine is 44.1) 2. detailed list of all diets attempted in the past 5 years to present. Must include all diet attempts, physician supervised or not, with starting and ending weights and dates.  3. Detailed letter from primary care physician stating you are a candidate for bariatric surgery. Documentation must include complete medical history with all health problems and your diet history including weight history. 4. Documentation from a physician stating weight 5 years ago. 5. Psycho Eval 6. Recent thyroid panel. 7. Patient must write a letter explaining that you understand all risksand how you feel you will benefit from the surgery. 8. Family member must provide a letter stating they understand risks of the surgery and how they feel you will benefit from the surgery. *** After I spoke to Tricare this morning, the lady who consulted with a RN, told me that I do not need numbers 3 & 4. But like I said, this is the list of requirements that was given to me yesterday by my surgeon who has quite a bit of experience with Tricare Prime. The problem I'm having is that my PCM isnt the doc *****ferred me for the surgery to begin with, it was a diff doc because as we know, if your PCM doesnt have open appts, they send you to another doc within the same MTF. I'm having trouble communicating as well as booking any appts with my current PCM and the doc *****ferred me so if I dont have to get anything from them, then I prefer not to go through all fhe trouble that I forsee happening with them.  I really would like to hear from someone who recently delt with Tricare Prime South region regarding their RNY surgery and what they were required to gather for the approval process because my head is spinning. My PCM is never available for appts and I'm afraid to take the chance of booking an appt with a doc who doesnt agree that I need the surgery even tho I've already gone through everything and the consult.  HELP would be highly appreciated! Thank you, Tamara

I'm not Tricare South (I'm TriWest) but their policies are the same for Gastric Bypass. They both state:

Gastric bypass, gastric stapling, or gastroplasty -- to include vertical banded gastroplasty -- is covered when one of the following conditions is met:

1. The patient is 100 pounds 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 severe respiratory diseases), hypothalamic disorders, and severe arthritis of the weight-bearing joints.
2. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).

First Tricare requires you to get a referal to the surgeon. My PCM didn't need to write a letter, he just requested the referal. (I got that approved within 12 hrs.)
The only thing I need to submit from my surgeon is him stating why he thinks it is medically necessary, proof of my weight being over 200% (I don't have any co-morbidities) and the Psych eval.

Now, if you have co-morbidities you'd need to submit proof of these as well.

A 5 year medical history, sleep study (or oximetry study), 5% weight loss, detailed list of diet attempts in the last 5 years, signed document (by me and a family member) stating I've read their information notebook and understand the risks associated with the surgery.... were all a requirement from my surgeon, not Tricare.

That said, my surgeon's office won't submit to insurance until I had all requirements (their's and Tricare's) done. I'm currently still waiting on my psych doc to get my eval to my surgeon's office. Should get it today or tomorrow, hopefully.

Hope this helps some. Good luck!!
Andi

http://www.obesityhelp.com/morbidobesity/members/insurers.ph p Wanted to add. You can go to the above link, click on your state, under T find Tricare and read what others on OH had been through with them.

Tamara, I sent you a PM.  I have Tricare South also.  I didn't have to "gather" anything for the approval process, my surgeon's office did all of that for me.  YOU won't submit anything to Tricare, your surgeon's office will.  I've never heard of Tricare asking for the list of things you posted, and my husband and I have been dealing with Tricare for a lot of years. Anyway, PM me back if you have more questions, I'll be happy to help...I know how important this is to you!

I just had all of my information submitted last week to Tricare South. The only thing I had to send in was the psych eval, a detailed letter from the surgeon stating why I needed this surgery and then for good measure (not because it was required) I sent a letter explaing why I felt like I needed the surgery and that I understood that this was a life long commitment.  I  was however denied, but not because of missing paperwork, but because I did not have any comorbidities.  But I think that they read my file wrong becasue I am 200% of my ideal weight and for that category they say you do not have to have comorbiditites.  So I am going to appeal.  Good luck with everything, keep us posted!