Tricare Prime Is A Piece Of Crap

Do not get your hopes up if you approval for office visits from Tricare. Everything will go fine until you need final approval for the actual surgery, then they will deny you. I was one week out from having surgery back in June and the Drs office called saying they have not gotten approval for the surgery--you do all the work call Tricare have the insurance person at the drs office work with you and then they deny at the last minute.
I was Tricare South, now I am in CA and am Tricare West I don't know if I'm willing to fight right now, I was so disappointed, I don't know if I can do it again. I might just wait and see if it gets approval over the next year or so. I cannot afford to to self-pay.
Lord knows my bmi is high enough and I have about 5 co-morbidities.

So I'm not trying to get you down. But please don't get your hopes up too high with Tricare you will get crushed.

I am so sorry you have had such a hard time. This is just what I am scared of. Tricare has approved my visits and requested a psych eval and a nutritional eval - I have this fear that everything will fall through right at the end.

I hope the best for you.

Minpinmom--That is the exact same thing I went through. All the evaluations--psych, nutrition, etc. and it all lead up to a denial.

Let me know how it goes. But just don't get your hopes too high and get totally crushed like I did.

Leah

Leah,

I think all of us with Tricare understand your frustration. I never really started the process because of that exact reason. I am looking into getting it done at a military hospital. I also have heard that some feel that when tricare renews their contract in O7, they will cover lap band. Some feel that way because tricare for life, champusva, medicaid and medicare all cover it now. So, just keep the faith and look into other options.

Be blessed

I totally feel for you and I'm in the same boat. I'm starting an appeal and I'm hoping for the best. Insurance companies are thieves and jerks! (um, yes, I have strong feelings about this)

I have a friend that wanted the Lap Band through Tricare and went through the whole process. They approved her for RNY and she fought them and lost. She had RNY and has never had a well day since. Keep up with the fight and good luck

I don't know if my friend was Tricare Prime. She was a Military wife, and I think it is simply Tricare.

I've started the Tricare Prime process, but if it gets denied, I'm wondering if I switch to Tricare standard it would be easier? I know I'd pay out of pocket some, but I could manage that. Does anyone know?

If you look at the Tricare Standard policy manual (online) is says that it is limited to RNY, Gastric BYpass and Gastroplasty. When you look at the Tricare Prime it says Obesity Surgery requires a psycholical evaluation - so, I am hoping my psych eval shows that I am looney and alllllll of my worldly problems will be solved by the band :-) ok, well that may be stretching it a bit. If I get denied, and my appeals fail, I will dig deeper into Tricare Standard, but I don't hold out too much hope. However, even the Tricare representatives say that the policy is due to be updated in Jan 07. That is really that far away.

W

I googled this last week, and I found a change dated 6/30/2006 labeled "Transmittal #94" with a whole bunch of other codes and stuff on it. It says the Lap Band procedure is now covered. I showed it to the doc at the base clinic and he looked into it, talked to the Tricare office, and agreed.

Here's the kicker - every facility is setting it's own guidelines for approving the procedure (per the LCDR I just spoke to). I'm at the mercy of the Jacksonville Naval Hospital, and apparently they require that I go through a 6-month weight-loss program supervised by the local (Key West) base docs.

Now, I can see where this is going. I know I will lose 20-maybe 30 pounds. Then I will be downgraded from morbidly obese to grossly obese and no longer qualify for the surgery. They will pat themselves on the back, I will gain the weight back, which I always do, and then we will transfer next summer and I will no longer be their problem.

Aaaaarrrrgggggghhhhhhhh!!!!!!!!!!!!

Dani

i looked up that information. I may be wrong but it says champusva. Champusva is for retirees. So, for those of us who are active duty dependents, tricare prime or standard is our only option. But I may be completely wronf. I am not very knowledgeable at all on this stuff. I've been married 6 yrs and I just learned what LES stands for lol. I hope so one weighs in on that info. I SOOOOOO hope I'm wrong!!!

Tricare used to be called Champus, so I don't know. I'm an active duty "dependent" (hate that word) and my doc used that message to get info for what we need to do for me, so you may want to run it by your PCM.

I called Tricare myself today and gave them the procedure code, and it IS covered - there are just a lot of BS prerequisites. I had to meet with the wellness coordinator on base and she was evil and said anyone who wants to lose weight bad enough can do it without help. She doesn't believe in WLS and put in my file that I refused to participate in her program because I told her if I did her 6-month program I'd eventually gain back any weight I lost. Isn't it fun dealing with military people?

Meanwhile, the nutritionist, surgeon and shrink all said I'd be an excellent candidate. And this B%&** can stop the whole process because she's got personal prejudices.

Welcome to TRICARE, your Military Health Plan

Tri-care has change its policy

New TRICARE Policy Adds Weight-Loss Options (Article 2) A recent change in TRICARE policy now provides coverage for laparoscopic adjustable gastric banding (Lap Band® surgery), opening new avenues of treatment for those fighting morbid obesity. This policy change is retroactive to Feb. 1, 2007. If you’ve had Lap Band surgery since Feb. 1, 2007, and qualify under the new policy guidelines outlined below, you may submit a claim for reimbursement or, if you submitted a claim and it was denied, you may appeal the denial.
Lap Band surgery is a minimally invasive procedure that can help you shed excess body weight. The Lap Band shrinks your stomach and restricts how much food you can eat at one time.
You are eligible for Lap Band surgery if you meet any one of the following conditions:






You are 100 pounds over the ideal weight for height and bone structure and have one of these associated medical conditions:

• Diabetes mellitus
• Hypertension
• Cholecystitis
• Narcolepsy
• Pickwickian syndrome (or other severe respiratory disease)
• Hypothalamic disorder
• Severe arthritis of the weight-bearing joints

You are 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.

You have had an intestinal bypass or other surgery for obesity and, because of complications, require a second surgery (a takedown).

For more information about Lap Band surgery, talk to your doctor about the benefits and risks of the procedure.



Gastric Bypass








TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
• Is 200 percent or more over ideal weight for height and bone structure
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)

It's really weird to hear about all of the Tricare Prime denials. I started this process March 4th with my initial consultation and had an approval by Tri-West Prime within couple of days. No psych eval. and I went to a nutritionist on my own accord. I was banded on April 18th.

I wonder why there are so many denials, are they giving you any reason at all for the denial?

Tri-Care just change their policy in March 2008