Tricare questions

mrskotz8 · 05-28-2009, 08:36 PM

Hello! My name is Joanna and I am at the early stages of LAP-BAND® approval. I just got approved for the initial appointments today. I just have a question about the qualifications for Tricare. My current weight is 273. Im 5'5 so my ideal weight range according to metlife chart is 127-141 for medium frame. Does that mean I atleast have to be 254 (127x2) to qualify for the 200% or will they do the make it 282 (141x2). Sorry if im confusing. I think im reading too much into things and confusing myself! Any help would be appreciated! thanks :)

RestlessMonkey · 05-28-2009, 10:03 PM

contractors must apply 100 pounds (or 200%) to both the lower and higher end of the

weight range

I cut this from the tricare manual I found online. So you'd have to weigh more than double BOTH/EITHER, or 254-282 (assuming the metlife table you used is the most current)

So no, you won't qualify. Tricare is a stickler from what I've heard.

i should say per this you won't qualify for the 200%. You should let your surgeon guide you through this though; don't let 9 pounds stop you.

mrskotz8 · 05-28-2009, 10:26 PM

So I have to be atleast 282 to qualify for the 200%? I might not have to gain more than 5 pounds. Im 273 on my scale...on a dr's scale im closer to 280

RestlessMonkey · 05-28-2009, 10:29 PM

You'd be safest to call tricare and ask, or ask the person who handles insurance claims at your doc's office. I am no pro; I didn't even handle MY claim; the nice lady at the hospital where my doc is head of bariatrics handled everything for me. I just googled "tricare requirements for LAP-BAND® surgery" and found that.

chantel03 · 05-29-2009, 05:16 AM

the 200% isnt the only thing that matters though.
do you have any comorbids?
ive found people on here going thru tricare with a 37 bmi and getting approved. i would make sure you get all your test done first and then see what your doc says. if tricare denies you, you can always gain weight and then get an appeal.

amonroy · 05-29-2009, 08:06 AM

I have tricare and I believe you can also be 100 lbs over your ideal weight and have co-morbitities also. Do you have any health conditions? I had no problem at all getting approved although I did start out at a 42 BMI but I never had any trouble with them. I would call them just to get some clarification. Good Luck.

Hazeleyes · 05-29-2009, 10:04 AM

I also have tricare and was approved by being 100lbs overweight and with added co-morbitities which were hypertension and borderline diabetes check with tricare for details good luck

talkalot1981 · 05-29-2009, 05:39 PM

I am going through Tricare as well. I am 5'4" and 239 and I have hypertention. I did have to gain 6 lbs though. I have a friend in NC who is getting the surgery June 16th. She is 5'10 and weighs 277. She has no co-morbities and she got approved no problem. But I guess Tricare can be picky with who they want to approve. I have my first consult with my new surgeon June 3rd, so I guess I will find out.

Good luck, I hope you get approved.... Jennifer

talkalot1981 · 05-29-2009, 05:46 PM

TABLE 1
1999 METROPOLITAN HEIGHT AND WEIGHT TABLES FOR
MEN AND WOMEN
According to Frame, Ages 25-59
WOMEN
Weight in Pounds (In Indoor Clothing)*

HEIGHT

SMALL

MEDIUM

LARGE

(In Shoes)+

FRAME

Feet

Inches

4

10

102-111

109-121

118-131

4

11

103-113

111-123

120-134

5

0

104-115

113-126

122-137

5

1

106-118

115-129

125-140

5

2

108-121

118-132

128-143

5

3

111-124

121-135

131-147

5

4

114-127

124-138

134-151

5

117-130

127-141

137-155

5

6

120-133

130-144

140-159

5

7

123-136

133-147

143-163

5

8

126-139

136-150

146-167

5

9

129-142

139-153

149-170

5

10

132-145

142-156

152-173

5

11

135-148

145-159

155-176

6

0

138-151

148-162

158-179

Indoor clothing weighing 5 pounds for men and 3 pounds for women.

+ Shoes with 1-inch heels

Source of basic data Build Study, 1979. Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980.
Copyright© 1996, 1999 Metropolitan Life Insurance Company
Courtesy of the Metropolitan Life Insurance Company.

I found this on line. I think this is the newest one. I barely qualify. I might have to stuff my bra or wear weights. You should qualify.

mrskotz8 · 05-30-2009, 12:47 AM

Thanks to all the responses. Yes I know that its either 100 pounds over with 1 comorbiditie or 200% overweight. As far as comorbidities go, if I have any, I dont know about them. I dont go to the dr much therefore even if I did have them, I dont have them documented so im shooting for the 200%. I would shoot for hypertension because every time I go to the dr they mention something about it but this last time when I went to get the referral, it was 110/70 (go figure). I have my consult on June 29 so I guess i'll wait and see what the surgeon says.

chantel03 · 05-30-2009, 12:55 PM

good luck hun,
im in the same boat as you but opposite. im shooting for the 100 pounds since i dont qualify for 200%. i know i have arthritis and AVN (hip disease) but i dont know if it will be enough. i guess we'll just have to hope for the best!

lmnlineman · 06-03-2009, 01:07 AM

I have Tricare as well and I was approved for being 100 lbs overweight and having a BMI over 40. Having comorbidities gives you a much better chance of getting approved. Are you going through a Military Treatment Facility? I had mine at NMC Portsmouth, VA 2 weeks ago. There was a woman that went in for bypass before I was banded, was no where near 100 lbs overweight or near a BMI of 40. I was shocked when she told me that was what she was there for since she didn't look like she weighed too much more than my goal weight. If she was approved, I am betting you have a pretty good chance at it. I just thought I'd share that with you. Plus, at the hospital I was banded at just started giving you the choice of LAP-BAND® or Realize Band. I got the Realize. So far, so good. I wish you the best of luck!

lnmlisa · 06-06-2009, 08:03 AM

I have tricare also and just got my approval this week. But when I went to my pcm for my LAP-BAND® referral he also put in a referral for a sleep test; which indicated that I have sleep apnea... a co-morbidity. I am 5'2 sometimes they measure me as 5'3 thought, but I weigh 250 lbs and I had no problems getting approved. My surgeons office walked me though everything, told me what appts I needed to have and even suggested who I should see for those appts. So once you have your consult w/your surgeon I think you will have a better idea of what you will need to do to get approved. Good Luck!!

chrystinaw · 07-02-2009, 05:35 AM

** Questions**
I called Triwest and they told me that my first doctor appt for my consultation is approved and the reason they had “Modifications” on there is because I didn't chose my doctor yet. I did choose my doctor and made my appt, yay! Has anyone been denied after the first (approved) consultation with the surgeon?

I forgot to ask the lady I talked to on the phone from Triwest. Can I print out the approved status I got online and bring that to the doctor or do I have to wait for the letter in the mail?

Another thing I saw on my online status that I don't quite understand and I forgot to ask is about the other thing on there. There are two things with approved with modifications...
~"office consultation: Approved w/Modifications " &
~"office/outpatient visit, new: Approved w/Modifications"
So I know I'm approved for the consultation but what is "office/outpatient visit, new"?, it says I'm approved for it but I don't know what that’s for...I'm thinking it’s the next appt after the consultation but I don't know, just asking to see if anyone has had this on their status online or approval letters and if they might know the answer. It’s a holiday weekend because of the 4th so I won’t be able to call until Monday so that’s why I’m asking you guys :)

Thanks for all the answers on my questions really appreciate it!!!