Tri Care said NO! But have other questions

[poohmsg 13]

So I had talked to my doctor about the sleeve and suggested we try the referral process, we called Tri Care and they shot us down even before the Dr wrote the referral. 1. They still don't cover the sleeve 2. I would have to gain at least another 50 pound or have a obesity related medical condition (which I don't, but am 105 pounds over weight) we were also told I did not even meet the requirements for the other 2 procedures either. So my question is since it appears that I am going to self pay do baratric surgeons have such strict rules to have the procedure done? Also what are some suggestions to finding a surgeon to do the procedure? I have seen several people going to Mexico to have it done, and while I like saving money I am still kinda leaning toward to having it down here in Texas. Thanks for any suggestions you may all have!!!

Melissa

[Tiffykins 673]

Hey Melissa,

What is your BMI? The requirements are BMI 35 with at least 2 co-morbidities, or BMI of 40 without co-morbidities.

The sleeve is covered at military hospitals on post/base, but not by civilian surgeons

Dr. Nick Nicholson

Dr. Wade Barker

Dr. David Kim

Are the 3 surgeons I researched for my revision when I was trying to get my revision from band to sleeve covered and approved and was looking at self-pay options. All of my family is in D/FW Texas so I would be close to family/friends if I had to go that route.

I'm not sure what area of Texas you are in, but there are some great surgeons in San Antonio and Houston.

If you need anything, feel free to contact me. I've gone round and round with Tricare for 2 years now on the sleeve so I'm fairly well-versed.

[Rootman 1,101]

One of these days I'm going to write a post about why NOT to get your sleeve surgery in Mexico to answer a lot of these questions and bring up issues concerning this. BTW, I got my surgery in Mexico in December.

While I suspect that most places, even Mexican, have some standards I have YET to hear of one person being turned down by them. If you have the cash and are fat they would probably operate on you the same day.

I went here: http://www.hospitaljerusalem.com.mx/ paid $5000 out of pocket (which MAY of been less than my co-pay & etc. had I gone with insurance) plus travel and hotel for 3 nights.

I am satisfied and realize I got exactly what I paid for. I've lost, well, look at my banner below. It's been a LOT easier than ANY diet I have EVER been on. I have some concerns on the fact that so far it has decimated my appetite and I am struggling to down more than 600 calories a day and I'm not getting quite enough Protein either. I hope this will get better - other's with longer experience with the sleeve have suggested it will.

WHY I CHOOSE MEXICO: I was having a LOT of health problems at 375 lbs and gaining - blood sugar was all over the place, BP was elevated, pulmonary problems made worse by my weight and joint problems. I never pursued insurance, I was privy to a conversation about 2 others in my company that have been "yanked around" by insurance for well over a year trying to get bariatric surgery. I just didn't want to wait, quite frankly I didn't think I would make it another year.

It was the right choice for ME.

[twoboysandagirl 109]

I was just about to have an RNY surgery from a civilian provider when I found out that he was a bit crooked he was asking for $6500 up front that he claimed insurance would not cover. I called tricare and they told me to absolutly NOT pay it and they suggest another provider. That surgeon wouldnt even see me the receptionist said I would have to gain 50 pounds to qualify for Tricare to pay for surgery. Anyway...I went back to my pcm and she suggested I go to the nearest MTF that did the surgery. She reminded me there would be NO out of pocket expenses. I have to drive the 3 hours for all my appointments and of course the surgery but I think the entire experience of the MTF was OUTSTANDING. If you can travel to a MTF then you will not need to deal with Tricare. I do get tricare to cover my gas and mileage when I go for follow ups and all the pre op appointments. I will also like to add that they may have a LOT of hoops for you to jump through. And it may take some time to get the actually surgery date but I was ok with that.

Good Luck to you not matter what route you take.

[seniorsleever 17]

Where in Texas are you? I'm in Corpus, and my surgeon is Dr. Nilesh Patel in San Antonio. Self-pay for everything is $14,000.

[poohmsg 13]

My BMI is 40.1 but they said my I had to be 200% over my idea body weight to qualify. Do you know if Darnall Hospital here in Killeen does the procedure. I go to a off post provider and am not sure if that makes a difference to them or not. I am even willing to travel to San Antonio to the military medical facilities if need be. I have awhile to figure this all out I can't have the procedure done until Aug when my husband comes back from deployment anyway just very frustrating already.

Hey Melissa,

What is your BMI? The requirements are BMI 35 with at least 2 co-morbidities, or BMI of 40 without co-morbidities.

The sleeve is covered at military hospitals on post/base, but not by civilian surgeons

Dr. Nick Nicholson

Dr. Wade Barker

Dr. David Kim

Are the 3 surgeons I researched for my revision when I was trying to get my revision from band to sleeve covered and approved and was looking at self-pay options. All of my family is in D/FW Texas so I would be close to family/friends if I had to go that route.

I'm not sure what area of Texas you are in, but there are some great surgeons in San Antonio and Houston.

If you need anything, feel free to contact me. I've gone round and round with Tricare for 2 years now on the sleeve so I'm fairly well-versed.

[Tiffykins 673]

My BMI is 40.1 but they said my I had to be 200% over my idea body weight to qualify. Do you know if Darnall Hospital here in Killeen does the procedure. I go to a off post provider and am not sure if that makes a difference to them or not. I am even willing to travel to San Antonio to the military medical facilities if need be. I have awhile to figure this all out I can't have the procedure done until Aug when my husband comes back from deployment anyway just very frustrating already.

You qualify. I do not know about that MTF, call them and ask.

Once your husband returns, have your PCM put in a referral to that particular MTF if they perform VSG. I do believe WIlford Hall in San Antonio in Lackland is performing the sleeve now. Don't quote me on it because surgeons come and go as you know, but you might be able to go there. I see an off-base PCM and it was no big deal to get a referral to our MTF here. As long as you have Prime, you can go there. So, that will not make a hill of Beans difference.

I've been trying to get on tricare.mil all day and it appears their server is being a douchebag. Do not rely on what the idiots on the phone say.

Do you have any of the following?

High Blood Pressure

Diabetes (or borderline diabetes)

High cholesterol

Joint pain/issue in the weight bearing joints such as knees, hips, ankles, back

Thyroid issues

PCOS

Get your PCM to write a letter of support, if you need templates, or guidelines for this, let me know, I have them saved LOL.

Any of those will help you get through the hoops. You do not necessarily be "approved" with Tricare to have it done at a MTF, you just have to meet the minimum requirements. You're a 100lbs overweight (strap some ankle weights on under boot cut or flare-leg jeans when you weigh in next time). YES, I just told you what so many people (especially military wives) do to get approval when they are on the cusp.

[poohmsg 13]

WOW had not thought of doing that with the weights! I will give them a call tomorrow and see what they say. I do not have any of the medical issues you listed but there is a family history of them for sure. My mom had a very debilitating heart attack a few years ago due to her weight, high blood pressure, and diabetes. My dad also has a weight problem and high blood pressure. I just want to get something done before it effects me as well. Thank you for the help I will let you know what they say.

[akt614 0]

sorry to jump in on this post-- but am i hearing correctly that you can have a sleeve done at an MTF but not through a civillian? if so- Im in Florida and Im not very familiar with any MTF's around here, the closest being Patrick AFB... it says that it is a clinic though, can it be done there?

Hey Melissa,

What is your BMI? The requirements are BMI 35 with at least 2 co-morbidities, or BMI of 40 without co-morbidities.

The sleeve is covered at military hospitals on post/base, but not by civilian surgeons

Dr. Nick Nicholson

Dr. Wade Barker

Dr. David Kim

Are the 3 surgeons I researched for my revision when I was trying to get my revision from band to sleeve covered and approved and was looking at self-pay options. All of my family is in D/FW Texas so I would be close to family/friends if I had to go that route.

I'm not sure what area of Texas you are in, but there are some great surgeons in San Antonio and Houston.

If you need anything, feel free to contact me. I've gone round and round with Tricare for 2 years now on the sleeve so I'm fairly well-versed.

[Tiffykins 673]

sorry to jump in on this post-- but am i hearing correctly that you can have a sleeve done at an MTF but not through a civillian? if so- Im in Florida and Im not very familiar with any MTF's around here, the closest being Patrick AFB... it says that it is a clinic though, can it be done there?

That is correct, VSG is NOT a covered procedure with Tricare outside of MTF. I am not sure if Patrick AFB offers VSG, you would have to call. My surgeon just PCS'd to MacDill AFB, his name is Dr. Michael Michel (pronounced Michelle). Eglin AFB is where I had my VSG performed.

Until Medicare fully endorses and picks up VSG, Tricare is NOT going to cover it with civilians.

You can use this MTF locator to call ALL branch MTF to see if they offer VSG:

http://www.tricare.mil/mtf/

[Lizbeth 16]

I was told by tricare yesterday you could get approved with a civilian provider if your mtf does not do the procedure. I have an appt. tomorrow with my pcm to try and get a referral for the vsg. I am almost 100 lbs overweight have pcos, high cholesterol and some joint pain. I was told by a friend who had a vsg via tricare that I should qualify for the surgery with no problem. Hoping it goes well. I will keep you all posted on my journey.

[Tiffykins 673]

I was told by tricare yesterday you could get approved with a civilian provider if your mtf does not do the procedure. I have an appt. tomorrow with my pcm to try and get a referral for the vsg. I am almost 100 lbs overweight have pcos, high cholesterol and some joint pain. I was told by a friend who had a vsg via tricare that I should qualify for the surgery with no problem. Hoping it goes well. I will keep you all posted on my journey.

Just be very careful. As they will tell you that you'll get approved, and when the doc submits everything, they could very possibly come back with a huge denial. The ONLY person I know who has been approved with a civilian is a lady who is on Tricare for Life, her husband is retired, and once you get on Tricare for Life, you pick a health plan kind of like with Medicare. . . Anyways, she had to switch to Standard, and is only seen at John Hopkins, their children are seen on post, and continue with Prime.

I've had friends in every Tricare region appeal, and even had one take it to the Congressional complaint level and have all been denied.

I would call back, get the ICD-9 that Tricare is approving with civilians to make sure you can approved. The ICD-9 code is not authorized procedure by Tricare per their guidelines.

If you get it approved, please come back and report the ICD-9 and what steps your surgeon's office took to get approved with a civilian. Many people are told that they can get it covered, they jump through the hoops, and then as soon as the paperwork is submitted, and then they get denied with the only option being RNY or the Band.

If one surgeon can get it approved, then all have to be approved, and considering for over 2.5 years, we've been fighting with Tricare to get approval. It's the same crap they pulled before they started approving the band. I was outright denied with a civilian and my revision was medically necessary, and I was still within the BMI requirements.

[Lizbeth 16]

Just be very careful. As they will tell you that you'll get approved, and when the doc submits everything, they could very possibly come back with a huge denial. The ONLY person I know who has been approved with a civilian is a lady who is on Tricare for Life, her husband is retired, and once you get on Tricare for Life, you pick a health plan kind of like with Medicare. . . Anyways, she had to switch to Standard, and is only seen at John Hopkins, their children are seen on post, and continue with Prime.

I've had friends in every Tricare region appeal, and even had one take it to the Congressional complaint level and have all been denied.

I would call back, get the ICD-9 that Tricare is approving with civilians to make sure you can approved. The ICD-9 code is not authorized procedure by Tricare per their guidelines.

If you get it approved, please come back and report the ICD-9 and what steps your surgeon's office took to get approved with a civilian. Many people are told that they can get it covered, they jump through the hoops, and then as soon as the paperwork is submitted, and then they get denied with the only option being RNY or the Band.

If one surgeon can get it approved, then all have to be approved, and considering for over 2.5 years, we've been fighting with Tricare to get approval. It's the same crap they pulled before they started approving the band. I was outright denied with a civilian and my revision was medically necessary, and I was still within the BMI requirements.

I will let you know how it goes. I will also ask my friend to post her experience on here as well. It would be pretty crappy if they are approving some and not others. The best of luck to you!

[Tiffykins 673]

I will let you know how it goes. I will also ask my friend to post her experience on here as well. It would be pretty crappy if they are approving some and not others. The best of luck to you!

Thanks so much. I had my revision performed at an MTF over 2 years ago so I'm all set, it's all the other spouse's out there getting denied and then settling for a surgical option they really do not want just because they are desperate to have some sort of WLS.

So, if anyone can give details on how they got it covered, the surgeon, location, either Tricare Prime, Standard, Prime Remote, Tricare for Life, ICD-9 codes, process and procedures that had to be completed before VSG was approved, all of that information can be used as ammo for other spouses.

It's illegal for them to approve it for some dependents and deny others. I've been fighting with Tricare and trying to help my friends with appeals and congressional complaints to get it covered with Tricare Prime or Standard with civilian surgeons.

[akt614 0]

Thank you for this information!! I think MacDill will be closer than Ft. Gordon Army Base. I did call the Tricare office at Patricks and she was very helpful in telling me what Ill need to do. Since I have a civillian PCM id have to first switch over to a PCM AT patricks, then go through the referral process to be switched to another MTF that offers the VSG! Im so happy that I was able to find out.. I really want to go through with the surgery but did NOT want to settle with the band or gastric bypass... I am so thankful I found this site!!!

That is correct, VSG is NOT a covered procedure with Tricare outside of MTF. I am not sure if Patrick AFB offers VSG, you would have to call. My surgeon just PCS'd to MacDill AFB, his name is Dr. Michael Michel (pronounced Michelle). Eglin AFB is where I had my VSG performed.

Until Medicare fully endorses and picks up VSG, Tricare is NOT going to cover it with civilians.

You can use this MTF locator to call ALL branch MTF to see if they offer VSG:

http://www.tricare.mil/mtf/