I'm so upset! Can't get my sleeve!

meriteri · July 19, 2010

I got a call last wk from a hospital, that I was referred out to for bariatric surgery. I was confused because I thought I was going to have my surgery at an MTF. So I called the MTF and they said that because I have a nueromuscular disease they felt it would be best to refer me to somewhere else. The problem with this is that Tricare doesn't cover the sleeve off-post. She said my options are the lapband or bypass! I called the new hospital and they said I have to go to the seminar, fax over my pysch. eval and maybe have more tests like sleep test etc. I asked if they have heard of Tricare maybe covering the sleeve soon and they have not. So now I have no idea what to do? Self pay is not an option. Being a military wife & stay at home Mom we can't afford any payment plans. So now I have to decide should I try to do this on my own once again or wait and hope that one day it will be approved? Or should I go forward and choose the band or bypass. If I do go forward I think I would rather have the bypass than the lapband. Another thing I'm worried about is what if tricare doesn't approve me for any wls because of my condition. But I just can't decide what to do, and what would be best. Any advice would be appreciated thanx!

mila1013 · July 19, 2010

oh how confusing. if they refered you can't you use that to help you, that they don't have any providers that can do the surgery on base? can you talk to someone else? anyone esle on base that can help you? i mean it is not your fault that you can't have it where they want you to, try to find someone who can help you with this, everyone picks different sugery types for different reasons, it is very difficult to pick the surgery type as it is based on so many reasons, hope you get some answers soon....

Mila

SarahD. · July 20, 2010

I'm so sorry that you are going through this. I'm with Mila. I would keep calling and asking questions. Since the base doesn't/can't perform them, they might have ideas of where to go and what to do. Do you know of anyone else with Tricare who has had the sleeve? If so, how did it work for them? I would ask around, even consider starting a thread here about it to see what answers/ideas you might get from others. I hope it works out for you and you get what is best for you!

Tiffykins · July 20, 2010

Unfortunately, until Medicare covers VSG nationwide, Tricare Prime nor Standard will cover it. I've fought it, I've helped friends fight it, and they are not gonna budge. I've dealt with it for over a year.

Personally, if I were in your shoes, I would not settle for RNY, and don't do the band. That's just based on my personal experience. Don't settle for something that you have to live with for the rest of your life.

What all of the case managers, patient advocates, and claims managers I've spoken to, they foresee coverage no later than 1 Jan 2011, and no earlier than 1 Oct 2010.

The only way my revision from band to sleeve was covered is because I had it at a MTF. If I could not have had it there, I would have had my band removed and stayed fat. There is no way, I would have gotten another band, nor RNY. No one could pay me to have RNY, sorry just not gonna settle for something that I know would not work for me personally with all the long term complications, and all of my friends in real life that have major complications that have been post-op for 5+ years, not to mention the regain stats for RNY.

I'm sorry you are going through this. I personally would wait unless you are willing to do all the research, and really look hard at RNY. For me, and my personal opinion, both the band and RNY are not options that one should have to settle on.

meriteri · July 20, 2010

Thanks everyone! And Tiffykins you are right I don't want to settle! I did call Humana Military and talked to someone about the possibility of the sleeve being covered in the future and she had no clue and didn't even know what the surgery was. I have decided to call the MTF tomorrow and plead my case. While in the process of getting everything needed for surgery I did have an appt. with my neurologist(something I did on my own, not required). He was very supportive about having wls, said that my condition shouldn't be a problem and that in fact losing weight could help my condition. So anyways, I'm just going to call & see if somehow I can meet with the anesthesiologist and surgeon to change their minds. Wish me luck!

Tiffykins · July 20, 2010

Thanks everyone! And Tiffykins you are right I don't want to settle! I did call Humana Military and talked to someone about the possibility of the sleeve being covered in the future and she had no clue and didn't even know what the surgery was. I have decided to call the MTF tomorrow and plead my case. While in the process of getting everything needed for surgery I did have an appt. with my neurologist(something I did on my own, not required). He was very supportive about having wls, said that my condition shouldn't be a problem and that in fact losing weight could help my condition. So anyways, I'm just going to call & see if somehow I can meet with the anesthesiologist and surgeon to change their minds. Wish me luck!

I'll keep you in my thoughts. I've fought with a friend from CA all the way to the congressional level, and it's been denied. I've written letters, emails, made so many phone calls. I'm extremely passionate about this subject, and stay on top of it. The day it's covered it by Tricare off base/post, I'll be singing it from the rooftops.

Get a letter of clearance from your neurologist that should help significantly.

lamsunshine · July 20, 2010

I don't understand I was actually surprised when they told me the VA approved my sleeve. Why would the VA cover it, and not Tricare.

Tiffykins · July 20, 2010

The VA is a gov't ran facility just like MTFs. If the surgeons do them, are qualified, their paychecks are the same regardless of surgery performed.

On the outside world, every surgeon charges a different fee, and each surgery has different requirements.

Just like my boob job and Tummy Tuck can/will be covered at an MTF but I'd pay out of pocket with a civilian.

Plus, surgeons at MTF/VA facilities need practice, and those procedures do not change the surgeon's paycheck either. They get the same pay on the 1st and 15th regardless.

lamsunshine · July 20, 2010

I'm actually fee based the VA's here dont do WLS, so they sent me to a civilian surgeon.

Tiffykins · July 20, 2010

I'm actually fee based the VA's here dont do WLS, so they sent me to a civilian surgeon.

Do you have Tricare for Life, or Tricare Prime or Tricare Standard?

lamsunshine · July 20, 2010

No I'm a Vet, so I go to the VA Hospital.

Tiffykins · July 20, 2010

No I'm a Vet, so I go to the VA Hospital.

So, when my husband retires, we've been told we'd receive the Tricare for Life program and it's completely different and regulated differently than the current coverage he obviously has.

I haven't been down the road of seeing approval for veterans with civilians, but am interested in the process. If you care to share, please let us know how all of it goes.

I'll be interested to see if they approve the sleeve on the outside because with the few Tricare prime friends I have that had pre-approval, jumped through all the hoops, supervised diet, lab work, nutritional consult, psych eval, pre-surgery consults, all with civilians, then once the authorization was submitted, it was all denied because it's not an approved procedure for Tricare at this time.

Best wishes, and keep us posted on your progress.

lamsunshine · July 20, 2010

It is called fee based, and if I need to be seen for something for instance, I have Narcolepsy, and no Docs at the VA treat Narcolepsy, so they fee based me to a civilian doc, and I even got to choose the doctor, as long as the doctor is on the approved list. Then one time they wanted me to be seen for my sinus, and sent me to a fee based doctor for that. As far as being approved for the sleeve I am approved and my surgery date is August 24th, if for some reason the VA denies me, but they have already approved me, I will go postal. lol not really, I'm sure if they were going to deny it they would of a month ago, when my surgeon gave me my final approval, but time will tell. I'm going to call my fee based rep now, and make sure all is ok.

Edited July 20, 2010 by lamsunshine

Tiffykins · July 20, 2010

That's so awesome, and I'm so glad you've been approved. You're going to do awesome. . .

meriteri · July 20, 2010

Ok I called the MTF today and was told to call back this afternoon. So when I did the head nurse said the Dr. wants to do some more research on it. So I have to call back next wk. More waiting but that's ok. But now I'm having second thoughts because this is a learning hospital & the surgeon might not have much experience. But if he says he will do it, I think I might be brave & go for it! I don't know still frustrated & confused.