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Thread: Tricare prime - gastric bypass question

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    #1

    Tricare prime - gastric bypass question

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    Hi all!

    Ok so after 2 years of fiddling with the idea, last friday I called my PCM (civilian doc since I live far enough from base) who had a opening on Monday to see me to get a referall for surgeon. I decided to call the gastric surgeon to get an appt. hopefully in coming weeks but they had an opening on tuesday! So got that rolling, went to PCM who said she was on board. I picked up my pre appt. packet from surgeon and called the psychiatrist to get that rolling. They had an opening on tuesday as well!
    So all got rolling, saw surgeon today, passed the psych appt. surgeon referred me to nutritionist who has an opening on thursday. OMG the surgeon even said she hasnt seen anyone get there appts out of the way in one week. I am really hoping this is a good sign!!!!!!!!!
    So my height is 5'5" and weighed in today at 255 (20 pds lower than I was 2 months ago) and my BMI was 47. talk about a shock to the number system
    I am really hoping this all goes through by next week, this is just so exciting!!!!!!!!

    I did have one concern though, hoping it gets bypassed. My insurance says have to be 100 pds overwieght with co morbid or 200 % over without co morbid. I am under the 200% but the insurance lady at surgeon says with that BMI she has yet to see someone rejected. HOping she is right
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    #2
    It's actually 100 lbs overweight or 100% over- aka twice as much as you should be. If your surgeon submitted your request saying you have a "small frame" 255 could be 100% overweight for 5'5. There are several different charts they can use dependent on bone structure. Surgeons are in the business of making money, along with their other responsibilities, so they are very good at wording their requests properly to get their patients approved. Good luck! I had the surgery just over a year ago.

    Also, you should go visit the newbie section of the forum and post an intro! We'd love to get to know you.
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    Thanks for the reply Loving! I dont have a clue how she is wording it. I showed the finance lady the sheet from tricare and she said dont worry, I have yet to have tricare not approve somone with a BMI of 47. I am actually large framed and 26 pds from double my ideal weight. Guess I will have to wait and see what happens. I am still going to double myself up and have a sleep study done just in case tricare diapproves. I just really hope htey dont. I would LOVE to have this done by thanksgiving. New year new me!!!
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    The nice thing about Tricare is that weight-loss surgery referrals are assigned a case manager who reviews each case individually and determines eligibility. It gives it an element of personal care that I haven't received in other areas of my medical coverage thus far (not that I have complaints about other parts of Tricare particularly). I was just on the edge of qualifying when I first went to my surgeon, and then I lost about 17 pounds at the surgeon's request which took me out of the qualifying range. But they decided to base it on my starting weight and approved my request anyway.

    The sleep study is a VERY good idea either way, because if you do have sleep apnea that's something you'll want to watch out for whether or not you have the surgery. And you can always re-submit your request with additional information later if they decide the info they have doesn't qualify you immediately.
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    Quote Originally Posted by Loving View Post
    The nice thing about Tricare is that weight-loss surgery referrals are assigned a case manager who reviews each case individually and determines eligibility. It gives it an element of personal care that I haven't received in other areas of my medical coverage thus far (not that I have complaints about other parts of Tricare particularly). I was just on the edge of qualifying when I first went to my surgeon, and then I lost about 17 pounds at the surgeon's request which took me out of the qualifying range. But they decided to base it on my starting weight and approved my request anyway.

    The sleep study is a VERY good idea either way, because if you do have sleep apnea that's something you'll want to watch out for whether or not you have the surgery. And you can always re-submit your request with additional information later if they decide the info they have doesn't qualify you immediately.

    Thanks and congrats on getting it done. May I ask which procedure you had? I am opting for RNY.
    I did type up a personalized letter that I will call and see if they will send it in with the packet. I more or less gave the horse and pony plead along with mentioning that my son is my hero (he is a cancer survivor of which I mentioned also) looking to tug at the heart strings ya know
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    Quote Originally Posted by armywifepayne View Post
    Thanks and congrats on getting it done. May I ask which procedure you had? I am opting for RNY.
    I did type up a personalized letter that I will call and see if they will send it in with the packet. I more or less gave the horse and pony plead along with mentioning that my son is my hero (he is a cancer survivor of which I mentioned also) looking to tug at the heart strings ya know
    I chose the RNY as well. I am 5'8 and started the process at 280, though my highest was closer to 300. I'm now 160, but pregnant. 150 was my lowest. It was a very exciting number to see. That is absolutely wonderful about your son.

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