TriCare Insurance WLS Benefits

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https://www.hnfs.net/bene/benefits/gastric_bypass_surgery.htm

Gastric Bypass (Surgery for morbid obesity)

Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty are covered. Laparoscopic adjustable gastric banding is covered effective February 1, 2007. (view Hospitalization Costs):

The following conditions must be met:

* The patient is 100 pounds over the ideal weight for height and bone 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; or

* The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions; and

* InterQual? criteria is used during the authorization process to determine if the requested surgery is appropriate and medically necessary. (InterQual? is a widely used product of McKesson Corporation that provides evidence-based clinical decision support for health plans, hospitals, government payors, and various other organizations.)

Authorization Requirements

TRICARE Prime beneficiaries require prior-authorization for all non-emergency inpatient procedures.

The following services are excluded (this list is not exhaustive):

* Office visits solely for the treatment of obesity

* Non-surgical procedures for treatment of obesity

* Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633).

* Gastric bubble or balloon

* Gastric wrapping/open gastric banding (CPT code 43843)

* Unlisted CPT codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

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Also, the patient can have a BMI of 35.5-39.9 as long as it is paired with a co-morbidity such as diabetes mellitus, hypertension or hypercholesterolemia.