MiCollins

Hi, I've posted this in a couple of spots, because I ran across it when I was on a Google Search for Gastric Sleeve Surgery Tricare There's a new ruling as of today for surgery for the morbidly obese. It states that if it is nationally accepted and medically necessary, it will be covered by tricare. Here's the link to the Federal Register Document on the Department of Defense Final Ruling. I think this could mean the sleeve will be covered as of march, but read it and see. There's a contact person and phone number in the document, so that might help with insurance issues. Here's the Link. My link DEPARTMENt oF DEFENSE Office of the Secretary 32 CFR Part 199 [DOD–2008–HA–0057] RIN 0720–AB24 TRICARE Program; Surgery for Morbid Obesity AGENCY: Office of the Secretary, DoD. ACTION: Final rule. SUMMARY: This final rule adds a definition of Bariatric Surgery, amends the definition of Morbid Obesity, and revises the language relating to the treatment of morbid obesity to allow benefit consideration for newer bariatric surgical procedures that are considered appropriate medical care. The final rule removes language that specifically limits the types of surgical procedures to treat co-morbid conditions associated with morbid obesity and retains the TRICARE Program exclusion of nonsurgical interventions related to morbid obesity, obesity and/or weight reduction. This final rule is necessary to allow coverage for other surgical procedures that reduce or resolve comorbid conditions associated with morbid obesity and the use of the Body Mass Index (BMI), which is the more accurate measure for excess weight to estimate relative risk of disease. As new technologies or procedures evolve from investigational into generally accepted norms for medical practice, the statutes and regulations governing the TRICARE Program allow the Department to offer beneficiaries these new benefits. These changes are required in order to allow the Department to provide these newer technologies and procedures for the treatment of morbid obesity as they evolve. DATES: Effective Date: This rule is effective March 16, 2011. ADDRESSES: TRICARE Management Activity, Medical Benefits and Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011– 9066. FOR FURTHER INFORMATION CONTACT: Gail L. Jones, Medical Benefits and Reimbursement Branch, TRICARE Management Activity, telephone (303) 676–3401. VerDate Mar<15>2010 14:08 Feb 11, 2011 Jkt 223001 PO 00000 Frm 00030 Fmt 4700 Sfmt 4700 E:\FR\FM\14FER1.SGM 14FER1 WReier-Aviles on DSKGBLS3C1PROD with RULES Federal Register /Vol. 76, No. 30 /Monday, February 14, 2011 /Rules and Regulations 8295 SUPPLEMENTARY INFORMATION: I. Background On December 27, 1982, the Department of Defense (DoD) published a final rule in the Federal Register (47 FR 57491–57493) that restricted surgical intervention for morbid obesity to gastric bypass, gastric stapling, or gastroplasty method (excluding all other types) when the primary purpose of surgery is to treat a severe related medical illness or medical condition. The severe medical conditions or illness associated with morbid obesity included diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian Syndrome (and other severe respiratory disease), hypothalamic disorders, and severe arthritis of the weight-bearing joints. The DoD also limited program payments to two categories of patients: (1) Those who weighed 100 pounds over their ideal weight with a specific severe medical condition; and (2) those who were 200 percent or more over their ideal weight with no medical complications required. Program payment was made available as well in cases in which a patient, who originally met the criteria, received an intestinal bypass, or other surgery for obesity and, because of complications, required a second surgery. Payment was allowed even though the patient’s condition may not have technically met the definition of morbid obesity because of the weight that was already lost following the initial surgery. All other surgeries including non-surgical treatment related to morbid obesity, obesity, and/or weight reduction were excluded. The DoD used the definition of morbid obesity, which was based on the Metropolitan Life Table and used then by other major health care plans, as well as reflected the 1982 general opinion regarding which cases justify surgical intervention. The DoD decided, at the time, that it was necessary to be very specific in benefit parameters due to fiscal responsibility and to ensure that Program beneficiaries were not being exposed to less than fully developed medical technology or procedures. At the time the current regulation was written in 1982, gastric bypass, gastric stapling, and gastroplasty methods were the recognized surgeries for morbid obesity. However, in recent years, other bariatric surgical procedures have evolved and some have a substantial body of literature to support their safety and efficacy. Unlike the original rule that listed the specific surgical procedures and the clinical conditions for which coverage may be extended; this final rule authorizes benefit consideration for those bariatric surgical procedures that have moved from the unproven status to the position of nationally accepted medical practice, as determined by the Program standard of reliable evidence. Also in 1982 during development of the current regulation for morbid obesity, overweight and obesity were typically measured with height-weight tables (such as the Metropolitan Life Table). The 1982 regulation restricted eligibility for bariatric surgery to individuals who exceed their ideal weight for height by 100 pounds with an associated severe medical condition, or 200 percent or more over their ideal body weight with no associated medical condition required. This final rule changes the Program definition of morbid obesity to reflect the current nationally accepted medical use of the BMI, rather than the typical assessed height-weight table (i.e., the Metropolitan Life Table), to determine an individual’s eligibility for bariatric surgical treatment. The BMI is the more accurate measure for excess weight to estimate relative risk of disease. Since there now are more than 30 major diseases associated with obesity, the final rule requires the Director, TMA, to issue specific criteria for co-morbid conditions exacerbated or caused by (morbid) obesity, as determined by the Program standard of reliable evidence. This final rule does not expand the TRICARE benefit for morbid obesity surgery. However, it does make the specific procedures that are covered, as well as the clinical conditions for which coverage may be extended, a matter of policy. In other words, new bariatric surgery procedures may be added to the TRICARE benefit structure as such procedures are proven safe and effective and are established as nationally accepted medical practice as determined by the Program standard of reliable evidence.

There's a new ruling as of today for surgery for the morbidly obese. It states that if it is nationally accepted and medically necessary, it will be covered by tricare. Here's the link to the Federal Register Document on the Department of Defense Final Ruling. I think this could mean the sleeve will be covered as of march, but read it and see. There's a contact person and phone number in the document, so that might help with insurance issues. Here's the Link. DOD Ruling DEPARTMENT OF DEFENSE Office of the Secretary 32 CFR Part 199 [DOD–2008–HA–0057] RIN 0720–AB24 TRICARE Program; Surgery for Morbid Obesity AGENCY: Office of the Secretary, DoD. ACTION: Final rule. SUMMARY: This final rule adds a definition of Bariatric Surgery, amends the definition of Morbid Obesity, and revises the language relating to the treatment of morbid obesity to allow benefit consideration for newer bariatric surgical procedures that are considered appropriate medical care. The final rule removes language that specifically limits the types of surgical procedures to treat co-morbid conditions associated with morbid obesity and retains the TRICARE Program exclusion of nonsurgical interventions related to morbid obesity, obesity and/or weight reduction. This final rule is necessary to allow coverage for other surgical procedures that reduce or resolve comorbid conditions associated with morbid obesity and the use of the Body Mass Index (BMI), which is the more accurate measure for excess weight to estimate relative risk of disease. As new technologies or procedures evolve from investigational into generally accepted norms for medical practice, the statutes and regulations governing the TRICARE Program allow the Department to offer beneficiaries these new benefits. These changes are required in order to allow the Department to provide these newer technologies and procedures for the treatment of morbid obesity as they evolve. DATES: Effective Date: This rule is effective March 16, 2011. ADDRESSES: TRICARE Management Activity, Medical Benefits and Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011– 9066. FOR FURTHER INFORMATION CONTACT: Gail L. Jones, Medical Benefits and Reimbursement Branch, TRICARE Management Activity, telephone (303) 676–3401. VerDate Mar<15>2010 14:08 Feb 11, 2011 Jkt 223001 PO 00000 Frm 00030 Fmt 4700 Sfmt 4700 E:\FR\FM\14FER1.SGM 14FER1 WReier-Aviles on DSKGBLS3C1PROD with RULES Federal Register /Vol. 76, No. 30 /Monday, February 14, 2011 /Rules and Regulations 8295 SUPPLEMENTARY INFORMATION: I. Background On December 27, 1982, the Department of Defense (DoD) published a final rule in the Federal Register (47 FR 57491–57493) that restricted surgical intervention for morbid obesity to gastric bypass, gastric stapling, or gastroplasty method (excluding all other types) when the primary purpose of surgery is to treat a severe related medical illness or medical condition. The severe medical conditions or illness associated with morbid obesity included diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian Syndrome (and other severe respiratory disease), hypothalamic disorders, and severe arthritis of the weight-bearing joints. The DoD also limited program payments to two categories of patients: (1) Those who weighed 100 pounds over their ideal weight with a specific severe medical condition; and (2) those who were 200 percent or more over their ideal weight with no medical complications required. Program payment was made available as well in cases in which a patient, who originally met the criteria, received an intestinal bypass, or other surgery for obesity and, because of complications, required a second surgery. Payment was allowed even though the patient’s condition may not have technically met the definition of morbid obesity because of the weight that was already lost following the initial surgery. All other surgeries including non-surgical treatment related to morbid obesity, obesity, and/or weight reduction were excluded. The DoD used the definition of morbid obesity, which was based on the Metropolitan Life Table and used then by other major health care plans, as well as reflected the 1982 general opinion regarding which cases justify surgical intervention. The DoD decided, at the time, that it was necessary to be very specific in benefit parameters due to fiscal responsibility and to ensure that Program beneficiaries were not being exposed to less than fully developed medical technology or procedures. At the time the current regulation was written in 1982, gastric bypass, gastric stapling, and gastroplasty methods were the recognized surgeries for morbid obesity. However, in recent years, other bariatric surgical procedures have evolved and some have a substantial body of literature to support their safety and efficacy. Unlike the original rule that listed the specific surgical procedures and the clinical conditions for which coverage may be extended; this final rule authorizes benefit consideration for those bariatric surgical procedures that have moved from the unproven status to the position of nationally accepted medical practice, as determined by the Program standard of reliable evidence. Also in 1982 during development of the current regulation for morbid obesity, overweight and obesity were typically measured with height-weight tables (such as the Metropolitan Life Table). The 1982 regulation restricted eligibility for bariatric surgery to individuals who exceed their ideal weight for height by 100 pounds with an associated severe medical condition, or 200 percent or more over their ideal body weight with no associated medical condition required. This final rule changes the Program definition of morbid obesity to reflect the current nationally accepted medical use of the BMI, rather than the typical assessed height-weight table (i.e., the Metropolitan Life Table), to determine an individual’s eligibility for bariatric surgical treatment. The BMI is the more accurate measure for excess weight to estimate relative risk of disease. Since there now are more than 30 major diseases associated with obesity, the final rule requires the Director, TMA, to issue specific criteria for co-morbid conditions exacerbated or caused by (morbid) obesity, as determined by the Program standard of reliable evidence. This final rule does not expand the TRICARE benefit for morbid obesity surgery. However, it does make the specific procedures that are covered, as well as the clinical conditions for which coverage may be extended, a matter of policy. In other words, new bariatric surgery procedures may be added to the TRICARE benefit structure as such procedures are proven safe and effective and are established as nationally accepted medical practice as determined by the Program standard of reliable evidence.

Hi Everyone, I came across this on a google search this morning. Apparently, the Department of Defense has finally ruled to not disqualify particular types of weight loss surgery, but just requires it to be medically necessary and particularly points to using BMI as a determination (but doesn't specify exactly how) Here's the link to the Federal Register for TODAY - FEB 14, 2011 Federal Register http://www.gpo.gov/fdsys/pkg/FR-2011-02-14/pdf/2011-3207.pdf Looks like it is effective March 2011 I cut and pasted here also in case the link doesn't work. DEPARTMENT OF DEFENSE Office of the Secretary 32 CFR Part 199 [DOD–2008–HA–0057] RIN 0720–AB24 TRICARE Program; Surgery for Morbid Obesity AGENCY: Office of the Secretary, DoD. ACTION: Final rule. SUMMARY: This final rule adds a definition of Bariatric Surgery, amends the definition of Morbid Obesity, and revises the language relating to the treatment of morbid obesity to allow benefit consideration for newer bariatric surgical procedures that are considered appropriate medical care. The final rule removes language that specifically limits the types of surgical procedures to treat co-morbid conditions associated with morbid obesity and retains the TRICARE Program exclusion of nonsurgical interventions related to morbid obesity, obesity and/or weight reduction. This final rule is necessary to allow coverage for other surgical procedures that reduce or resolve comorbid conditions associated with morbid obesity and the use of the Body Mass Index (BMI), which is the more accurate measure for excess weight to estimate relative risk of disease. As new technologies or procedures evolve from investigational into generally accepted norms for medical practice, the statutes and regulations governing the TRICARE Program allow the Department to offer beneficiaries these new benefits. These changes are required in order to allow the Department to provide these newer technologies and procedures for the treatment of morbid obesity as they evolve. DATES: Effective Date: This rule is effective March 16, 2011. ADDRESSES: TRICARE Management Activity, Medical Benefits and Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011– 9066. FOR FURTHER INFORMATION CONTACT: Gail L. Jones, Medical Benefits and Reimbursement Branch, TRICARE Management Activity, telephone (303) 676–3401. VerDate Mar<15>2010 14:08 Feb 11, 2011 Jkt 223001 PO 00000 Frm 00030 Fmt 4700 Sfmt 4700 E:\FR\FM\14FER1.SGM 14FER1 WReier-Aviles on DSKGBLS3C1PROD with RULES Federal Register /Vol. 76, No. 30 /Monday, February 14, 2011 /Rules and Regulations 8295 SUPPLEMENTARY INFORMATION: I. Background On December 27, 1982, the Department of Defense (DoD) published a final rule in the Federal Register (47 FR 57491–57493) that restricted surgical intervention for morbid obesity to gastric bypass, gastric stapling, or gastroplasty method (excluding all other types) when the primary purpose of surgery is to treat a severe related medical illness or medical condition. The severe medical conditions or illness associated with morbid obesity included diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian Syndrome (and other severe respiratory disease), hypothalamic disorders, and severe arthritis of the weight-bearing joints. The DoD also limited program payments to two categories of patients: (1) Those who weighed 100 pounds over their ideal weight with a specific severe medical condition; and (2) those who were 200 percent or more over their ideal weight with no medical complications required. Program payment was made available as well in cases in which a patient, who originally met the criteria, received an intestinal bypass, or other surgery for obesity and, because of complications, required a second surgery. Payment was allowed even though the patient’s condition may not have technically met the definition of morbid obesity because of the weight that was already lost following the initial surgery. All other surgeries including non-surgical treatment related to morbid obesity, obesity, and/or weight reduction were excluded. The DoD used the definition of morbid obesity, which was based on the Metropolitan Life Table and used then by other major health care plans, as well as reflected the 1982 general opinion regarding which cases justify surgical intervention. The DoD decided, at the time, that it was necessary to be very specific in benefit parameters due to fiscal responsibility and to ensure that Program beneficiaries were not being exposed to less than fully developed medical technology or procedures. At the time the current regulation was written in 1982, gastric bypass, gastric stapling, and gastroplasty methods were the recognized surgeries for morbid obesity. However, in recent years, other bariatric surgical procedures have evolved and some have a substantial body of literature to support their safety and efficacy. Unlike the original rule that listed the specific surgical procedures and the clinical conditions for which coverage may be extended; this final rule authorizes benefit consideration for those bariatric surgical procedures that have moved from the unproven status to the position of nationally accepted medical practice, as determined by the Program standard of reliable evidence. Also in 1982 during development of the current regulation for morbid obesity, overweight and obesity were typically measured with height-weight tables (such as the Metropolitan Life Table). The 1982 regulation restricted eligibility for bariatric surgery to individuals who exceed their ideal weight for height by 100 pounds with an associated severe medical condition, or 200 percent or more over their ideal body weight with no associated medical condition required. This final rule changes the Program definition of morbid obesity to reflect the current nationally accepted medical use of the BMI, rather than the typical assessed height-weight table (i.e., the Metropolitan Life Table), to determine an individual’s eligibility for bariatric surgical treatment. The BMI is the more accurate measure for excess weight to estimate relative risk of disease. Since there now are more than 30 major diseases associated with obesity, the final rule requires the Director, TMA, to issue specific criteria for co-morbid conditions exacerbated or caused by (morbid) obesity, as determined by the Program standard of reliable evidence. This final rule does not expand the TRICARE benefit for morbid obesity surgery. However, it does make the specific procedures that are covered, as well as the clinical conditions for which coverage may be extended, a matter of policy. In other words, new bariatric surgery procedures may be added to the TRICARE benefit structure as such procedures are proven safe and effective and are established as nationally accepted medical practice as determined by the Program standard of reliable evidence.

From Tricare's website Tricare Weight Loss Surgery 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) So it looks like BMI isn't the issue. It's the number of pounds you are over your ideal weight. They use the MetLife charts and the upper number for medium frame size. So if you are 5'3" - you go by the 5'4" measure (because it says "your height in 1 inch heels") Here's the chart Met Life Ideal Weight Chart So if you're 5'4" in heels, your ideal weight for a medium framed woman is between 124 and 138. Add 100 pounds to the 138 = 238. YOU ALSO must have a comorbid condition on their list : diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints. Now I think this also includes sleep apnea under the narcolepsy category, but not sure. OR If you are 200 % above your ideal weight. This would mean the same person at 5'3" (5'4" in heels) would need to weigh above 276. This doesn't require a health condition. I fall in the first category, and am beginning my process. Hopefully I get approved. Hope this helped. Michelle

Wish me luck. I'm in the North Region. I understand that they use the Metlife ideal weight charts, so by that, I'm 100 pounds overweight. I also have sleep apnea and high blood pressure. Hope this makes me a shoe-in. anyone in the Hampton Roads area have this done? Michelle