Who has Tricare Prime?

[Randi 0]

At what point do you know if you have been approved or not? Dr. Spiegel in Houston ONLY does Lapband and I just got my referral in the mail saying that Tricare has authorized 5 visits. WTF would I need 5 freakin visits for if they dont let you have the surgery?

WTF

minpinmom,

Tricare also authorized me four visits, but denied the surgery. However, my surgeon had already warned me that she had yet to see Tricare approve lapband and that her surgery group always peformed bypass surgery on Tricare insured patients.

[DaniKLargo 0]

I called Tricare today and gave them the billing code the dr gave me - I think 43770? Anyway they said it IS covered if the conditions are met. That's the kicker - nobody could give me the conditions.

There's the rule about being at least 100 pounds overweight, which seems to be carved in stone. My question was - what is my ideal body weight? Well it's according to some life insurance tables, then you have to compute your body type, which apparently depends on the measurement of the bone on your elbow. WTF?

Then there's the requirement that you have a 6-month (or 5, depending on who I ask) medically supervised weight loss program prior to approval. If you lose down to say, 99 pounds overweight vs. 100, you no longer qualify. If you don't lose weight, you failed the program and no longer qualify. Either way I'm SOL.

The wellness coordinator told me today that my BMI has to have been documented at least at 40 for the past 5 years. Where did that come from? I dunno. She gave me a flyer from the Jacksonville Naval Hospital for gastric bypass and told me the requirements are the same.

Then there's the psych eval, nutrition counseling, sleep studies, and various approvals from every specialist I've ever seen.

If anyone else has any information that would help with this process, please post it. I'm so frustrated with the arbitrary prereqs and dealing with the military in general.

[Randi 0]

Dani,

I find it interesting that Tricare just disapproved my request for the band and now tell you that it's covered. This must be a very recent change. I think I'll call tomorrow to see if I get the same answer.

[DaniKLargo 0]

Randi -

Please let me know what Tricare says. Did they give you a reason for turning you down? There's so much mixed information out there, combined with the prejudices of the military doctors in general this is all really frustrating.

It seems that nobody really knows the requirements. The paperwork is submitted to "The Nurses" at Tricare. What do they look for? Nobody could tell me. Hmmm - very mysterious and Oz-like.

My next meeting is with my PCP on tuesday, so I'll see how it goes from there.

Good luck with all this.

Dani

[Randi 0]

Randi -

Please let me know what Tricare says. Did they give you a reason for turning you down? There's so much mixed information out there, combined with the prejudices of the military doctors in general this is all really frustrating.

It seems that nobody really knows the requirements. The paperwork is submitted to "The Nurses" at Tricare. What do they look for? Nobody could tell me. Hmmm - very mysterious and Oz-like.

My next meeting is with my PCP on tuesday, so I'll see how it goes from there.

Good luck with all this.

Dani

Dani,

I called 1-800-444-5445 today. Told the representative that I wanted to check the coverage on a certain CPT Code. Gave her CPT Code 43770. She looked it up and said, "No, Adjustable Gastric Band is not covered."

You may want to call the hospitals in your region to see if any of them are doing lapband implants. I know Walter Reed is doing them, but last I heard they were only accepting patients in their region.

[DaniKLargo 0]

OK get this - I called the 800 number, and I was told that it is covered, and that the provider has to have it precertified - but then it will be turned down because it's not really covered. Huh????

I was also told that some MTFs perform the procedure and don't need authorization.

And... the Tricare rules vary per region - I'm in the south, and it's covered but it's not. :couch2:

Next step - I'm going through the tricare website and requesting written clarification. Wish me luck.

[Randi 0]

Dani,

I don't know what to tell ya. My husband seems to think Tricare may be covering lapband in some regions, but not in all. Or, the Tricare representative could be referring to the Gastric Bypass, which is a weight loss procedure covered by Tricare. So that would kinda explain the "covered, but it's not" response you received.

If you can find a Military Treatment Facility (MTF) that is peforming lapband and that will accept you as a patient -- problem solved. Fortunately, Tricare doesn't care what procedures/surgery you have done at an MTF because it's no money out of their pockets. The only time Tricare coverage kicks in is when the procedure/surgery CAN'T be performed at an MTF and that's when the hoop jumping you're experiencing now begins.

Good luck on getting written clarification. I suspect you'll be referred to Tricare Policy Manual 6010.54-M, Chapter 4, Section 13.2, Change 48 (dated September 8, 2006) which cleary states:

DESCRIPTION

Morbid obesity means the body weight is 100 pounds over ideal weight for height and bone structure, according to the most current Metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200 percent or more of ideal weight for height and bone structure.<O:p</O:p

<O:p</O:p

POLICY<O:p</O:p

A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one of the following conditions is met:

<O:p</O:p

1. 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.<O:p</O:p

<O:p</O:p

2. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.<O:p</O:p

<O:p</O:p

3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).<O:p</O:p

<O:p</O:p

B. In determining the ideal body weight for morbid obesity using the Metropolitan Life Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the weight range. Payment will be allowed when beneficiaries meet all requirements for morbid obesity surgery including the ideal weight within the newly determined range.<O:p</O:p

<O:p</O:p

EXCLUSIONS<O:p</O:p

A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction.<O:p</O:p

<O:p</O:p

B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of morbid obesity is unproven (CPT2 procedure code 43645, 43845, 43847 or 43633).<O:p</O:p

<O:p</O:p

C. Gastric bubble or balloon for treatment of morbid obesity is unproven.<O:p</O:p

<O:p</O:p

D. Gastric wrapping/gastric banding (CPT2 procedure code 43843) for treatment of morbid obesity is unproven.<O:p</O:p

<O:p</O:p

E. Unlisted CPT2 procedure codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

EFFECTIVE DATE

Laparoscopic surgical procedure for gastric bypass and gastric stapling (gastroplasty), including vertical banded gastroplasty are covered effective December 2, 2004.

[mcw12985 0]

Here's a question: I just got banded on the 5th through BCBS. My husband is joining the AF this month and so I got banded just in time before our good insurance ran out.

Do you-all think that Tricare will cover fills or complications? I really hope so, or I may be up a creek without a paddle.

[Randi 0]

Here's a question: I just got banded on the 5th through BCBS. My husband is joining the AF this month and so I got banded just in time before our good insurance ran out.

Do you-all think that Tricare will cover fills or complications? I really hope so, or I may be up a creek without a paddle.

I believe fills are billed under different CPT Codes and that fills with or without fluoro would carry two different CPT codes. You can ask your current doctor what CPT Codes he/she uses to bill for fills, then call Tricare to see if the fills are covered. Hopefully by next year Tricare will cover lapband and so it should follow that fills will also be covered.

[DaniKLargo 0]

Randi -

Thanks for your info. I think you're right, and it's hopeless. I'm not sure I'm going to wait until next year to see if it's covered in 2007, and I'm heartsick at the thought of subjecting myself to any more military health-care "professionals" who tell me that if I really wanted to lose weight I could do it without surgery.

Luckily my employer offers Aetna, and I turned it down when I took the job because I thought Tricare would be fine for me. Now I just need to research Aetna policies, or bye-bye 401K. Either way, I'm done dealing with those bozos. Even if they covered it they'd probably farm me out to the lowest bidder and it would be a disaster. (When I had a lump removed from my breast it was by a doctor who specialized in acne treatment. You should see the size of my scar.)

Thanks so much for always replying to my posts. It's nice to know there's someone out there going through the same thing, although I wish we had happier experiences to share

Dani

[DaniKLargo 0]

Here's a question: I just got banded on the 5th through BCBS. My husband is joining the AF this month and so I got banded just in time before our good insurance ran out.

Do you-all think that Tricare will cover fills or complications? I really hope so, or I may be up a creek without a paddle.

I agree with Randi on the fills - get the codes and call Tricare. As far as complications, when I met with my Tricare reps, they gave me a copy of Tricare Policy Manual 6010.54-M, August 1, 2002, Chapter 4, Section 1.1 which states basically that complications from noncovered surgery or treatment are not covered unless the complication is "an unexpected complication which is untoward based on prior clinical experience with the procedure."

I took this to mean that slippage, blockage, erosion, and infection are not covered, but if say, your big toe falls off, they'll help you.

Welcome to the "dependents" club. (I hate that word!!!)

[Randi 0]

Randi -

Thanks for your info. I think you're right, and it's hopeless. I'm not sure I'm going to wait until next year to see if it's covered in 2007, and I'm heartsick at the thought of subjecting myself to any more military health-care "professionals" who tell me that if I really wanted to lose weight I could do it without surgery.

Luckily my employer offers Aetna, and I turned it down when I took the job because I thought Tricare would be fine for me. Now I just need to research Aetna policies, or bye-bye 401K. Either way, I'm done dealing with those bozos. Even if they covered it they'd probably farm me out to the lowest bidder and it would be a disaster. (When I had a lump removed from my breast it was by a doctor who specialized in acne treatment. You should see the size of my scar.)

Thanks so much for always replying to my posts. It's nice to know there's someone out there going through the same thing, although I wish we had happier experiences to share

Dani

Dani,

Before you withdraw the money from your 401K read this:

http://www.smartmoney.com/debt/calculator/index.cfm?story=borrow401k

Also, the beauty of the military health care professional in the Surgery clinic that does bariatric procedures, is that once you PCM refers you, there are no more questions asked. At that point, the only criteria is do you qualify and how soon can you get the prerequisite testing done (sleep study, mammogram, pap smear, echocardiogram, complete blood panel, etc.). How do I know?

Well, before I discoved the lapband, I was actually pursuing the full blown gastric bypass at Wilford Hall Medical Center (WHMC). However, after I attended the information meeting with the surgeon and learned that the gastric bypass was a one way procedure, required lifetime supplementation because of the malabsorbption, and that the journey may be fraught with unrecoverable complications, I knew there had to be a better way.

WHMC has been trying to get a their Ajustable Gastric Band (lapband) program up and running for well over a year, but just don't have the resources. So, that's why I've been exploring the other options available to me for payment. But, if the VA won't cover it and I can find an MTF that does the procedure, that's where I'm going. Self-pay is the last option I plan to pusue.

[DaniKLargo 0]

Thanks for the link Randi - I'll definitely consider that, since it's looking like self-pay for me. I researched Aetna, and it's not looking good. Due to my yo-yo dieting, I don't have a documented BMI high enough consistently over the past 5 years. Oh well.

On the other hand, I'm feeling very good right now. I wrote a letter of complaint about the LCDR at the base clinic that was so rude to me about my weight. I've never written a letter like this before, but wow it feels good. Now I just have to get up the nerve to mail it. Then I'll derfinitely be switching to Tricare Standard - no way do want to see her for my pap smear after she finds out about the letter

[Randi 0]

Mail it. Mail it! . . . and don't forget to ensure the hospital commander gets a copy. Then BOLDLY make your appointment to see different provider on that team or another team for that matter.

[sharon2u 0]

I ran into a fient at Wall World yesterday his wife has tri care prime and he has tri care for life, according to him the lap band is covered but he might be guessing I do know with all of his medical problems he knows his Insurance I told him to check first, his wife is thinking about having it done. The lap band