Tricare Prime, anyone?

[Kassie B. 1]

I'm at the very beginning of my journey to a possible VSG. My husband is active duty Army and we have Tricare Prime insurance. The Tricare website says that they cover gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery). Would I be correct in assuming that VSG would be the same as vertical banded gastroplasty or gastric stapling??

I have yet to contact my PCM and discuss referral options in my area, so I'm literally at the VERY BEGINNING, but I thought this would be a good place to start asking questions.

Thanks in advance!

[Tiffykins 673]

Nope it's not the same.

VSG is NOT a covered procedure with Tricare Prime or Standard. You can however have it performed and covered 100% with a military treatment facility.

That probably doesn't make sense, but essentially it's covered if the MTF performs sleeves. If they don't you can not have it done with a civilian, even on a referral.

It is not covered, and won't be any time soon. I've fought Tricare for over 2 years now. Between myself, my 4 friends in every region of Tricare, it's not covered by civilians so you have to go to a MTF that performs and offers sleeves.

Tricare will not cover it until Medicare fully picks it up. Remember, Tricare is a government ran H M O type insurance.

I have had friends file appeals, even one took it all the way to the Congressional complaint level, got denied even at that level.

I'm an active duty Air Force wife. And, literally spent the last year and half, writing letters, emails, making phone calls for myself and friends trying to get definitive answers. I've called every region, every possible patient advocacy, etc etc.

It's not covered outside MTFs. If your MTF performs it, follow their program and have it there. If you see a civilian PCM, you will not be approved for VSG. I even had one friend in Virginia, jump through every insurance and surgeon requirement hoop, had a pre-cert letter and everything from Tricare. Final paperwork submitted, and DENIED.

If you see a civilian PCM, you'll need to get a specific referral to the MTF bariatric program. If you typically get kicked out to civilians, you are looking at RNY(bypass) or banding. That's the only 2 options with civilian surgeons.

[Dawn 16]

Kassie - I know there are a few MTFs in the DC area that do the sleeve but I'm not sure exactly which ones! We have Prime (but are retired) and my surgery was at the MTF here at West Point. It was SUPER easy for me as well, Doctor recommended me, I met with the surgeon and went through all the other appointments and had surgery, easy as pie!! LOL

Make an appt. with your PCM and see if they will recommend you and go from there! I am betting that since ya'll don't have an actual hosptial (just a clinic) that they may not do the surgery there but you should be able to go to an MTF in the area (but I have heard there is a wait list for the area!)

[fancy huh 5]

I'm at the very beginning of my journey to a possible VSG. My husband is active duty Army and we have Tricare Prime insurance. The Tricare website says that they cover gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery). Would I be correct in assuming that VSG would be the same as vertical banded gastroplasty or gastric stapling??

I have yet to contact my PCM and discuss referral options in my area, so I'm literally at the VERY BEGINNING, but I thought this would be a good place to start asking questions.

Thanks in advance!

Tiffykins, I'm sorry to say you are wrong..Tricare does pay for VSG.. I am a dependent my husband is also active army and I just had mine done on the 18 of Nov.. There are strps that tricare want you to take though and every post is different... So Yes is the answer to your question....

If you need more info give me a call I will inbox you my number and I will tell you what I had to do... from talking to your PCP to the surgery..

Good LUCK

[Dawn 16]

Tiffykins, I'm sorry to say you are wrong..Tricare does pay for VSG.. I am a dependent my husband is also active army and I just had mine done on the 18 of Nov.. There are strps that tricare want you to take though and every post is different... So Yes is the answer to your question....

If you need more info give me a call I will inbox you my number and I will tell you what I had to do... from talking to your PCP to the surgery..

Good LUCK

Did you have your surgery On post or off post by a civilian? If you had it on post then yes, some MTFs do it (mine did) but if you had it off post I'm really curious as to what all you did to get it approved because you would have been the first person we have met?

[Tiffykins 673]

Tiffykins, I'm sorry to say you are wrong..Tricare does pay for VSG.. I am a dependent my husband is also active army and I just had mine done on the 18 of Nov.. There are strps that tricare want you to take though and every post is different... So Yes is the answer to your question....

If you need more info give me a call I will inbox you my number and I will tell you what I had to do... from talking to your PCP to the surgery..

Good LUCK

Can you share how you got it covered with a civilian???? If you read my post correctly I specifically state that it is indeed covered at MTFs, but not with civilians.

Because every document, every rep, every customer advocate, every other surgeon and insurance coordinator I've talked to in 4 different states, Tri-West, Tricare south (Humana, and the region I'm in), and Tricare north all deny with a civilian.

So, since I'm wrong, and you've had it covered with a civilian, please share how you managed to get it covered with Prime with a civilian surgeon.

I'd like to get further information, how you out of the 100s of others that I've spoken with that have been denied, had a Congressional compliant denied, yet you were approved with a civilian surgeon.

Not sure if you didn't read my reply thoroughly, or but, you might want to reread what I posted.

I see a civilian PCM, and all my referrals get kicked to civilians so I honestly went through the wringer just to get a referral to on base provider because our system works a little different when we see civilians on base. We get to see off base providers because we are at a small base with tons of retirees, and appointments are very difficult to get in a timely manner. Plus, we do not live on base (9miles from the front gate), but we still get to see civis for everything.

I had my revision performed at a MTF and it was covered 100%.

[Tiffykins 673]

To the original poster:

1st step is to get a referral to a MTF that performs the sleeve (you might have to call around to see which ones offer it)

2nd step was an informational seminar, fill out some paperwork

3rd step they call for a consult with the surgeon

4th step was nutrition and psych consult

5th step was another consult with surgeon and to set a date

labs were pulled, chest xray, ekg, you might have to have a sleep study or stress test based on your own medical history

Every program is different but this was the steps that our program has set up

[Kassie B. 1]

Thank you, everyone. We don't have an MTF right here where I am, but there should be some rather nearby as Dawn suggested. If there's a wait, that'd be just my luck.

Rita, I'll call you in a few days... or early next week.

[Tiffykins 673]

Thank you, everyone. We don't have an MTF right here where I am, but there should be some rather nearby as Dawn suggested. If there's a wait, that'd be just my luck.

Rita, I'll call you in a few days... or early next week.

I've had 5 friends now go through the process here at our MTF, and it takes about 6-8 weeks to get all the appointments scheduled and completed. A surgery date has always happened within 2 months here so not big wait compared to others.

It depends on how many surgeons they have available to perform the sleeve. We had 2, then went down to 1, then back up to 2 so it kind of depends on each specific location and how back logged they are on bariatrics.

Here is a MTF locator link for you to try, that way you don't have to try to hunt down numbers.

http://www.tricare.mil/MTF/

[poohmsg 13]

Thanks Kassie for asking I am in the same situation you are. I am going to the Dr tomorrow to find out how to even get started since I have no idea. I have read several different things on if it is coverd or not the info everyone has shared has been more helpful. Good Luck!

Melissa

[Tiffykins 673]

Kassie, did you get any answers from the poster that stated it is a covered procedure outside of MTFs? I sent a private message and asked here, but obviously, I'm not getting a reply.

If she did get her VSG covered by Tricare prime OFF POST/BASE, please share the details so we can share this information with the other military spouses that really want VSG and do not have an MTF to go to that performs the sleeve.

This is vital information, and if you or Fancy Huh could post some details, and steps to get it approved outside having it at a military hospital, it would be greatly appreciated.

[Robin Lanzoni 1]

Awaiting elaboration with breathless anticipation since the MTF I'm about to try with is about 5 hours from my house. If I could get a civilian Dr, that would be terrific.

[Tiffykins 673]

Awaiting elaboration with breathless anticipation since the MTF I'm about to try with is about 5 hours from my house. If I could get a civilian Dr, that would be terrific.

Me too. . . I am currently trying to help 3 other military wives get approved or get to a long distance MTF for the sleeve.

Sadly, I have a feeling that we aren't going to get a response. I've sent messages, and posted here, but no replies.

I'm not holding my breath since I've once again called all the Tricare regions, and they are still stating it is an unapproved, non-covered service outside of MTFs.

[Robin Lanzoni 1]

Even if Prime started covering the sleeve, someone would have to find a network provider. How many Bariatric Surgeons accept PRIME? The closest surgeon to me that accepts STANDARD for the Band or RNY is over 2 hours away.

[Tiffykins 673]

Even if Prime started covering the sleeve, someone would have to find a network provider. How many Bariatric Surgeons accept PRIME? The closest surgeon to me that accepts STANDARD for the Band or RNY is over 2 hours away.

I agree. The closest surgeon that performs VSG is in Georgia, and down near Miami still over 4-8 hours away.