Tricare now covers VSG!

[tennessee1031 0]

As of 1/1/10 Tricare now covers the procedure- new cpt code- 43775. Ha! I gave the code to the docs office, they had never heard of it and used it on a patient that was closer to surgery than me and it was approved! It's been submitted for me and the status is still pending, but I'm checking 2 or 3 times a day to see that "A" for approved!! Such good news:)

[Tiffykins 673]

What region of Tricare are you in?

Because for those in the Tricare North, I've heard they are having a tough time getting approved. I know they've been covering them at MTF's but some people have Tricare Standard, or Prime and see a civilian.

I've been checking tricare.mil for coverage, but haven't seen any updates since August 2009.

[tennessee1031 0]

I have Prime in the South region. I haven't been able to find anything on the net and search pretty much everyday, but I did find this: Justia Regulation Tracker TRICARE Program; Morbid Obesity , - Department of Defense - 55792?55794 [E9?26042]

[Tiffykins 673]

Thank you I bookmarked it so I can pass it on.

[bertb 0]

I called tricare south and they told me it was an uncovered procedure. Do you have a contact that can confirm if VSG is approved? I am approved for a lap band, but would prefer the VSG. Surgery to be scheduled soon....

[tennessee1031 0]

So, here's the scoop. As you saw, my docs office called all excited that another Tricare patient was surprisingly approved for VSG. I got all excited. Pre-authorization submited; pre-authorization DENIED. I call Tricare and get a lady that said it's not covered- she wasn't very helpful. I hang up and call back and get someone very helpful. I give her the CPT code. She tells me: "yes, it's covered. It just says referral required".

Okay, so I proceed to ask why my pre-autho was denied. She looks into her "system" and she said: "humm, in this system it says gov't no pay." Apparently, they have 2 systems. She proceeds to say that the system that is usually most current says :referral req. The other: NO pay. It get's escalated to her manager for clarification. The manager said it was an error on their part and that it depended on which computer system the representative looked at as to what your answer would be. Really? Wow!

If you have Tricare. Submit for pre-authorization first. Doesn't hurt to try. They DID approve a lady right before me.

Still denied. But here's what I think: I think the currently DON'T cover it, but they soon will since there is current proposed regulation to update WLS options from Tricare to the 21st century.

Here's some good news (Maybe).... I did a little research (gotta love google) and I understand that when Tricare began covering the LapBand some time ago, they allowed reimbursement claims (and came through) for those that were previously denied the authorization.... Not sure how far they went back.... Maybe they'll do the same for VSG.

Here nor there. I'm back to paying out of pocket. My surgery is scheduled for Feb. 4th. I'm sooo excited.

[Tiffykins 673]

I called as well to find out if it's considered a covered procedure. I spoke with a manager in the "covered services" department, and in the claims department. Both confirmed that it's only covered as a procedure at a MTF. The claims department manager said they get 20-30 calls a day for the VSG, but they do not foresee Tricare covering it until Medicare is on board for covering it.

It requires the same eligibility requirements as RNY and the Band. The denial can be appealed if you have a medical reason to have the VSG vs. RNY or the Band. For example, the need to take NSAIDS, but many people are not successful appealing through Tricare.

I had my revision fully covered here in Florida, and there are several MTF (especially large Navy and Army MTFs) that are offering the sleeve as a covered procedure.

[clk 3,519]

Thanks for all of the information on this. I got the same answer as Tiffykins when I recently called - that it's not going to be covered in 2010.

I have Tricare Prime Overseas and it's definitely not covered here.

I think part of the confusion is also that just because a MTF does a procedure does not mean Tricare covers that procedure. Surgeons at MTFs do all sorts of surgeries on a wait list basis for things that are not covered under Tricare. For instance, my husband had a free vasectomy reversal (TMI, I know) and my friend had breast augmentation done. It depends on where you go and who the surgeon is, not to mention how busy they are and what surgeries they want to do.

Also, from what I hear it's much easier to get a revision done, or to get a surgery performed when you have some sort of complication to go with it that requires a surgery anyway.

I was also told that they will likely do repayments but not to count on that if I choose to self-pay. So don't count on reimbursement - though once Tricare does start covering this anyone that self-paid should try to get reimbursed. It can't hurt to try.

I'll just keep waiting and trying to lose this weight the old fashioned way in the meantime. They'll only do bands here, and I'm not even messing around with that nonsense.

~C

[leelee 0]

i am currently stationed overseas too. i'm going to be heading into my doctor's office sometime next week to discuss it with them. however, i am also planning on looking into it down town. surgery is relatively cheap over here, so if it isn't too much, i might be able to pay for the surgery out of pocket. still, it can't hurt to find out some info on base first, i guess. :thumbup1:

[Sabrina 0]

I had mine done at an MTF no problemo. I realize it is too late now, but OP could you have had it done at Ft Campbell? I went to Mexico and got the band paced at my expense and on the DL when I was active duty. They saw me for the band and did fills at the MTF here even when I was still active. Said it was already in me, so what was the point in arguing LOL They also took it out - thank God - and then gave me the sleeve. By that time I was a dependent though and no longer AC myself.

[t001surg 0]

I have Tricare Standard and have been told that this is the only procedure recommended due to my prior surgery. Have you heard of any other Tricare patients who have been approved in the North region? What did they have to provide? :001_rolleyes:

[Tiffykins 673]

I have Tricare Standard and have been told that this is the only procedure recommended due to my prior surgery. Have you heard of any other Tricare patients who have been approved in the North region? What did they have to provide? :laugh0:

Definitely not covered even by Tricare Standard. Sorry, but I've worked the system every which direction, I've never had any luck getting approval, here in the South, my 3 friends in the North all went to Walter Reed, and my 2 friends in Cali went to a naval hospital. I have some friends in Texas, but they have Prime and had it covered at a MTF.

It's not an approved procedure, and won't be until Medicare picks it up.

[pcos_chick 23]

Not sure if this will help anyone else but...

I am a Tricare Prime Beneficiary. I live in the DC area. The DC Bariatric program(NNMC, Walter Reed and Belvior) is full and not accepting patients (you can't even get on the wait list.) However the Portsmouth/VAB/Norfolk area program IS accepting patients. After my referral was rejected by the DC area program I called down to NMCP confirmed they were accepting patients and called the referral management center at NNMC and they faxed my referral to NMCP. (Yay)

Do not call Tricare or Healthnet... they can not/will not help.

[NLWC.Christa 4]

I spoke with a woman in the TriCare authorization department today and she denied the sleeve as a non-covered service, but was able to change the code for me over the phone and approved the bypass. As Tiffy mentioned, she stated that they follow Medicare guidelines as far as covered procedures are concerned. BTW, we are a civilian doc and civilian hospital, there are no military facilities performing WLS in our area.

I do all of the insurance pre-determinations and pre-certifications in our office and for the life of me, I can never figure out TriCare. I've always been very fortunate to speak with helpful provider reps though who walk me through.

[Khy 16]

I have been told by the person that handles insurance claims for my surgeon that tricare does not currently cover it. She said she knew that it was on the table and being discussed but had no idea when or if it would be approved. She said she was hopeful because it is now being done in many military treatment facilities. I did not want to go the MTF route because I have had prior procedures there and they did not go well. I don't think the people they have are bad... I think they just have way too much to do.