Tricare is deflating my hopes

[SpeedyCheeks 0]

I think I'll post this in the insurance area

Just wanted to see if anyone has found a way around this...I've been referred for a band removal (Big Surprise, NOT!). I was hoping to get referred to the nearest MTF so I could hopefully revise to the VSG because if I have to go civilian I can only get RNY due to the Dr they want to send me to. I will not even consider RNY, severe malabsorption, stricture risks, the five year failure rate, etc. it's just not for me. Help

[Robin Lanzoni 1]

I am having my sleeve done at an MTF that's 5 hours from my house. It's going to be ALOT of work to get it done since their surgeon requires a 5 month program and monthly support group meetings. Man, this is going to be tough. I work full time and have an autistic child. I don't have family here to leave him with overnight. They have agreed to allow me to use a civilian Dr who accepts PRIME. I was told to have the Dr write some very specific phrases on his referral that states I'm over 60 miles from the nearest MTF... etc. I have not spoken with the surgeon but I have spoken with the nurse. She said they will try to work around things for me but not the time to surgery. Sure, I'd like it sooner but I'm 40 years old... what's another 5 months? Where do you live?

[SpeedyCheeks 0]

Robin thanks for the reply. Good luck to you with getting civilian approval for the sleeve. I understand about appointments and kids; I have an 11, nearly 3, and 1.5 yr, old believe me nobody wants to see me at an appt with them in tow. That's another reason I want to go to the base, it's 30 minutes closer than the Dr. I'll be 40 too really soon and was hoping for the revision around my birthday. I don't plan on telling anybody about the surgery and was hoping to just let them all jump to their own conclusion about me having a mid-life crisis or something. I really hope things go well for you...I'll be looking for updates.

[Tiffykins 673]

If you don't get the referral to the MTF, you can call a patient advocate or visit the post/base patient advocate and request the referral be changed. I've never had one denied, and about to go for my next "referral change" for fertility assistance. I'll get sent to our MTF for fertility even though I see a civilian PCM with Prime, and I refuse to go on base for fertility assistance. All of my referrals have been kicked to civilians, but I requested my referrals to the MTF for my revision and they did it without any fuss.

Best wishes ! ! !

[SpeedyCheeks 0]

Tiffykins thank you so much; I've called the base but only talked to the clinic. You're giving me hope at least, thank you, I'm going to dial the phone now...I'll update!

[SpeedyCheeks 0]

I called the pt advocate and was told that all the bariatric surgeons are away right now and to call back in a couple months. I'm assuming they are deployed or getting more training. I don't know if I can wait that long, if this band is really eroding I should probably get rid of it sooner rather than later. I am more than dissappointed.

[Tiffykins 673]

I called the pt advocate and was told that all the bariatric surgeons are away right now and to call back in a couple months. I'm assuming they are deployed or getting more training. I don't know if I can wait that long, if this band is really eroding I should probably get rid of it sooner rather than later. I am more than dissappointed.

You could always have the band removed, and then the sleeve in a second procedure which might be safer considering you're concerned about erosion.

Don't give up. It's an awful fight with Tricare and trying to get stuff taken care of, but it's totally worth it.

[MiCollins 0]

There's a new ruling as of today for surgery for the morbidly obese. It states that if it is nationally accepted and medically necessary, it will be covered by tricare. Here's the link to the Federal Register Document on the Department of Defense Final Ruling. I think this could mean the sleeve will be covered as of march, but read it and see. There's a contact person and phone number in the document, so that might help with insurance issues.

Here's the Link.

DOD Ruling

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD–2008–HA–0057]

RIN 0720–AB24

TRICARE Program; Surgery for Morbid

Obesity

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

SUMMARY: This final rule adds a

definition of Bariatric Surgery, amends

the definition of Morbid Obesity, and

revises the language relating to the

treatment of morbid obesity to allow

benefit consideration for newer bariatric

surgical procedures that are considered

appropriate medical care. The final rule

removes language that specifically

limits the types of surgical procedures

to treat co-morbid conditions associated

with morbid obesity and retains the

TRICARE Program exclusion of nonsurgical

interventions related to morbid

obesity, obesity and/or weight

reduction. This final rule is necessary to

allow coverage for other surgical

procedures that reduce or resolve comorbid

conditions associated with

morbid obesity and the use of the Body

Mass Index (BMI), which is the more

accurate measure for excess weight to

estimate relative risk of disease. As new

technologies or procedures evolve from

investigational into generally accepted

norms for medical practice, the statutes

and regulations governing the TRICARE

Program allow the Department to offer

beneficiaries these new benefits. These

changes are required in order to allow

the Department to provide these newer

technologies and procedures for the

treatment of morbid obesity as they

evolve.

DATES: Effective Date: This rule is

effective March 16, 2011.

ADDRESSES: TRICARE Management

Activity, Medical Benefits and

Reimbursement Branch, 16401 East

Centretech Parkway, Aurora, CO 80011–

9066.

FOR FURTHER INFORMATION CONTACT: Gail

L. Jones, Medical Benefits and

Reimbursement Branch, TRICARE

Management Activity, telephone (303)

676–3401.

VerDate Mar<15>2010 14:08 Feb 11, 2011 Jkt 223001 PO 00000 Frm 00030 Fmt 4700 Sfmt 4700 E:\FR\FM\14FER1.SGM 14FER1 WReier-Aviles on DSKGBLS3C1PROD with RULES

Federal Register /Vol. 76, No. 30 /Monday, February 14, 2011 /Rules and Regulations 8295

SUPPLEMENTARY INFORMATION:

I. Background

On December 27, 1982, the

Department of Defense (DoD) published

a final rule in the Federal Register (47

FR 57491–57493) that restricted surgical

intervention for morbid obesity to

gastric bypass, gastric stapling, or

gastroplasty method (excluding all other

types) when the primary purpose of

surgery is to treat a severe related

medical illness or medical condition.

The severe medical conditions or illness

associated with morbid obesity included

diabetes mellitus, hypertension,

cholecystitis, narcolepsy, Pickwickian

Syndrome (and other severe respiratory

disease), hypothalamic disorders, and

severe arthritis of the weight-bearing

joints. The DoD also limited program

payments to two categories of patients:

(1) Those who weighed 100 pounds over

their ideal weight with a specific severe

medical condition; and (2) those who

were 200 percent or more over their

ideal weight with no medical

complications required. Program

payment was made available as well in

cases in which a patient, who originally

met the criteria, received an intestinal

bypass, or other surgery for obesity and,

because of complications, required a

second surgery. Payment was allowed

even though the patient’s condition may

not have technically met the definition

of morbid obesity because of the weight

that was already lost following the

initial surgery. All other surgeries

including non-surgical treatment related

to morbid obesity, obesity, and/or

weight reduction were excluded.

The DoD used the definition of

morbid obesity, which was based on the

Metropolitan Life Table and used then

by other major health care plans, as well

as reflected the 1982 general opinion

regarding which cases justify surgical

intervention. The DoD decided, at the

time, that it was necessary to be very

specific in benefit parameters due to

fiscal responsibility and to ensure that

Program beneficiaries were not being

exposed to less than fully developed

medical technology or procedures.

At the time the current regulation was

written in 1982, gastric bypass, gastric

stapling, and gastroplasty methods were

the recognized surgeries for morbid

obesity. However, in recent years, other

bariatric surgical procedures have

evolved and some have a substantial

body of literature to support their safety

and efficacy. Unlike the original rule

that listed the specific surgical

procedures and the clinical conditions

for which coverage may be extended;

this final rule authorizes benefit

consideration for those bariatric surgical

procedures that have moved from the

unproven status to the position of

nationally accepted medical practice, as

determined by the Program standard of

reliable evidence.

Also in 1982 during development of

the current regulation for morbid

obesity, overweight and obesity were

typically measured with height-weight

tables (such as the Metropolitan Life

Table). The 1982 regulation restricted

eligibility for bariatric surgery to

individuals who exceed their ideal

weight for height by 100 pounds with an

associated severe medical condition, or

200 percent or more over their ideal

body weight with no associated medical

condition required.

This final rule changes the Program

definition of morbid obesity to reflect

the current nationally accepted medical

use of the BMI, rather than the typical

assessed height-weight table (i.e., the

Metropolitan Life Table), to determine

an individual’s eligibility for bariatric

surgical treatment. The BMI is the more

accurate measure for excess weight to

estimate relative risk of disease. Since

there now are more than 30 major

diseases associated with obesity, the

final rule requires the Director, TMA, to

issue specific criteria for co-morbid

conditions exacerbated or caused by

(morbid) obesity, as determined by the

Program standard of reliable evidence.

This final rule does not expand the

TRICARE benefit for morbid obesity

surgery. However, it does make the

specific procedures that are covered, as

well as the clinical conditions for which

coverage may be extended, a matter of

policy. In other words, new bariatric

surgery procedures may be added to the

TRICARE benefit structure as such

procedures are proven safe and effective

and are established as nationally

accepted medical practice as

determined by the Program standard of

reliable evidence.

[Disney 20]

Well, I got excited for about 30 seconds until I called the person under "For Further Information Contact", Gail Jones. She said the sleeve was still not covered, after I explained in detail what it was. Not sure she ever really understood me and don't think she ever heard of the Sleeve. Anyway, she said she would be looking into it this summer to see if it has proven to be 'effective'. She then said she would be checking into 'another' type of WLS that has to do with the 'pancreas and switch'. Ok, I THINK she was talking about the Duodenal Switch. Not sure on that one. Not sure she knew either...

So, bottom line... Tricare may or may not be checking into the VSG for approval this summer, and may or may not approve it depending on whether the powers that be find it "effective" enough.

She then explained that what this new info was really saying, is that now Tricare does not have to go through the higher ups to ask for approval anymore. They can decide whether or not a particular WLS is good enough themselves.

I believe I will keep my appointment with Dr. Aceves rather than wait for Tricare to come out of the stone ages.

Thanks for posting the info, just wish it were better news.