PCOS & Tri-Care Insurance Approval

Hey guys!

 

Has anyone been approved through Tri-Care Prime and was approved with PCOS as a co-morbidity?

 

Also, is anyone aware of Tri-Care’s policies when it comes to gastric-bypass surgery?

 

I am wishing to have the surgery and I have my consultation this Monday. I weigh 235 and my BMI is about 39.1. I know if I weight just five more pounds I’d be at a BMI of 40 but unfortunately that’s not the case (*sigh*).

 

Any advice or information about Tri-Care Prime and the approval process would be great guys!

 

Thanks!

 

Dee Dee

 

You know...I don't know if PCOS is considered a co-morbid or not.  I'm also not familiar with Tri-Care either...but from what I understand I think the standard for a BMI of 35-39 must have at lesat 2 comorbids like diabetes, hypertension, sleep apnea...stuff like that.  Good luck though!  I hope you get all your questions answered!  You might also want to post this on the Main board so that more people see your questions...good luck! Kristy

Thanks Kristy! ... and by the way your little one is too too cute... simply adorable! Congrats girlfriend! Dee Dee

Hi DeDe, I have TriCare Standard and I sailed through the approval process.  I have PCOS, among some other things. Here in a cut-n-past from the tricare handbook - this is for standard coverage but I assume it is the same qualifications for Prime other then you would probably have to chose a military facility  Hope this helps.

Obesity Treatment

 

TRICARE Standard coverage is limited to three types of surgical treatment for obesity: gastric bypass, gastric stapling, and gastroplasty, including “vertical banded” gastroplasty, when one of the following conditions is met:

• A patient is 100 pounds or more over the ideal weight for height and body 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.

• A patient is 200 percent or more of the ideal weight for height and body structure. An associated medical condition is not required for this category.

• A patient has complications from a non-covered surgical treatment for obesity, such as intestinal bypass, and needs one of the three surgical procedures that are covered. TRICARE Standard does not cover any other services, medications, or supplies related to obesity or weight reduction. Non-surgical treatment of morbid obesity, such as wiring the jaws, camps for obesity treatment, or special diets, are not covered

I have Tricare Prime (Army) at Fort Carson, CO. If your having your surgery at the Military Treatment Facility (MTF/Military Hospital) then your surgeon approves you...not Tricare. Talk to your doctor about it. I had mine here at Evans Army Hospital and that's how they told me about it. After a year you also get a FREE tummy tuck. Not every MTF does that but they do here. My BMI was 42 or so and I also have arthritis of the back so I was pretty much a shoe in. Good luck with everything!

I am trying to have my surgery done at a MTF and I would like to know the cost associated with this procedure??? I am in Atlanta and I have tried the process with a civilian doctor, however, TriCare did not approve- so, I am taking the MTF route- just wanted to know how expensive this can get; also, I spent money on a psych eval,  and nutrition eval- is all of this necessary with the MTF process??

Please respond asap.

Hi,
Let me know how it went with getting your approval. I am also in Atlanta. What MTF are you using?


Thanks,
Diana

Hello,  I am relocating to fort Carson in about a week and I am looking for a good PCM in the area.  I would like someone on post.  can you please send any recommendations you may have?

thanks

[email protected] 

I dont have the PCOS but i do have irregular periods and they listed that as a co-morbidity for my Tricare Prime. I am not having my surgery at a MTF but i did have to get my PCM on base to do my referral and she has to clear me for surgery 30 days prior to going in. I had no problems with getting approval from Tricare as a matter of fact my paper work was faxed to them this past Tuesday at about 2pm and i had an approval at 9am on Wednesday morning. My BMI was over 40 so i wasnt required to have the co's but they listed them anyways. As for the tummy tuck i have heard many people say that Tricare does it but i have not looked into this myself as of yet because i am not sure if they will pay for it outside of it being a surgeon at a MTF. If you have anymore questions please feel free to send me a message and i will help you out as much as possible because i know how confusing Tricare can be and I have been through it and i am willing to make anyone else's journey with it as easy as possible.

I am getting a tummy tuck for free  after I lose a majority of the weight through a MTF because I have had alot of problems alreay with sagging skin on my abdomen causing infections and my c section scar actually opens on me from time to time.  But incase you didnt know....EVERY military dependant as well as the military member themselves is ENTITLED to one free cosmetic surgery done through a MTF. ( there are ways of getting around the MTF but it aint easy...!!!!) Now alot of us have heard about this and then went back and said something to our doctors and they've just rooled their eyes at you and pressured you out the door. But it is TRUE. They dont like it and they dont want to give it to you...you basicly have to find someone on your side that will tell you the truth of course right no with the wounded there is a LONG waiting list but it is absoulutly true! I have three girl friends that are active duty that have gotten their breast done ( augmentation) Do a search on yahoo or google for Tri Care cpsmetic surgery and see what you can find :)