Veterans Administration and Lap Band Surgery?

[Pete53 0]

I am a 100% Service Connected Veteran and would like to know if anyone has experience or knowledge if Dallas VAMC will do my Lap Band. I know that the Doctors at Southwestern Medical School have to practice on somebody?

[Randi 0]

Pete,

I'm investigating that very thing myself. In fact, I went and enrolled for VA healthcare today, because TRICARE will only approve me for the gastric bypass not the lapband.

I know for a fact that CHAMPVA does pay for the lapband for veteran dependents and I'm hoping coverage for veterans is similar. I'm keeping my fingers crossed.

[Randi 0]

Pete,

I did some research and it looks like the VHA does cover bariatric surgery for Veterans. Here are what I believe to be applicable links:

http://www1.va.gov/SURGERY/page.cfm?pg=25

http://www.va.gov/move/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf#search=%22Veterans%20Health%20Administration%20bariatric%20surgery%22

http://www.va.gov/vatap/pubs/Bariatricfinalreport3-05.pdf

[Pete53 0]

Randi:

Thank you very much, that was quite a find :-)

I intend to make an appointment with my gatekeeper Doc and provide copies for her to help me.

I hope that you get someone at your VA who will help.

I will keep you advised on my progress. What a great Board.

Pete

[Randi 0]

Pete,

Glad I could help! You may want to do some more research on your own. In one of those links it said that the Veteran had to be involved in the VA MOVE program or a similar program for three months as part of the pre-evaluation for surgery. Also, I don't know where you live, but the facilities that perform the surgery are limited. I'm hoping I can get referred out locally because the nearest facility to me is about 4 to 5 hours away from where I live. That could cause problems for me if I get a fill and then find a day or two later that I need an unfill.

So, needless to say . . . research, research, research!

[DaniKLargo 0]

Randi - Thanks for the info. I am a veteran and my spouse is active duty. I didn't know I could still go through the VA if I have Tricare - that's what you're doing, isn't it?

I've just started the process of getting approved through Tricare Prime, and I wonder if this would be easier if I go through the VA. I read that Tricare requires a person to be 100 pounds overweight and do a 6-month weight loss program before being approved. My BMI is just over 40 w/ comorbidities but if I lose any weight at all on their 6-month program I won't be over the 100-pound mark and I won't qualify for the surgery. The VA doesn't seem to have that 100-pound rule, or did I miss that?

I'm also considering Tricare Standard, and as a last resort liquidating my 401K and paying for it myself.

I hope you'll keep posting on your progress with this, and I'll call the local VAMC tomorrow and see what they tell me. Good luck!

Dani

[Pete53 0]

The VA has a program that allows people with TriCare who are under 65 to use the VA with no copays. I forget what they call it. You can call your local VA and see if they participate.

Be advised that VA is not always a good optioon as there can be long delays but many Veterans feel that they get good care and the meds are pretty good.

[Randi 0]

Randi - Thanks for the info. I am a veteran and my spouse is active duty. I didn't know I could still go through the VA if I have Tricare - that's what you're doing, isn't it?

I've just started the process of getting approved through Tricare Prime, and I wonder if this would be easier if I go through the VA. I read that Tricare requires a person to be 100 pounds overweight and do a 6-month weight loss program before being approved. My BMI is just over 40 w/ comorbidities but if I lose any weight at all on their 6-month program I won't be over the 100-pound mark and I won't qualify for the surgery. The VA doesn't seem to have that 100-pound rule, or did I miss that?

I'm also considering Tricare Standard, and as a last resort liquidating my 401K and paying for it myself.

I hope you'll keep posting on your progress with this, and I'll call the local VAMC tomorrow and see what they tell me. Good luck!

Dani

Dani,

I am a Tricare Prime enrollee and recently submitted an application to receive VA medical benefits as well. My eligibility for VA healthcare is based on my percentage of service-connected disability.

Currently, Tricare will not cover the Adjustable Gastric Band (lapband). So, you may want to verify and get it in writing that Tricare Standard will either pay or reimburse you for the procedure (CPT Code 43770). I was told the Tricare contract is scheduled to change in January 2007. So, perhaps the lapband may be covered at that time.

Per current policy (http://manuals.tricare.osd.mil/), Tricare will cover Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty when one of the following conditions is met:

¨ 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.

¨ 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.

¨ The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).

I'm not certain what the VA policy is to be eligible for surgery, but the medical standard is a 40 or greater BMI with or without comorbidities or at least a 35 BMI with one or more comorbidities. Each insurance company sets additional hoop jumping criteria. Tricare hoops are the 6 months diet and exercise regimen and the 100lb requirement based on the Metropolitan Life Insurance weight tables.

Although depleting your 401k is definitely an option, there's a few other possibilities you may wish to explore. The first is locating Military Treatment Facilities in your Tricare region and contacting each one to determine if they're performing lapband implants (www.tricare.osd.mill), locating a Bariatric clinic that will finance the procedure at a discounted rate for self-pay patients (e.g. www.Wishcenter.org), or other finance options: http://www.lapband.com/lapband/costsandinsurance.do. Also, peruse this thread to see if there may be some different options to consider: http://www.lapbandtalk.com/showthread.php?t=19742

Honestly, I've considered the self-pay option myself, but have refrained from using it so far because I'm not ready to chance having to pay for a second surgery should implant removal become necessary.

[Randi 0]

I am a 100% Service Connected Veteran and would like to know if anyone has experience or knowledge if Dallas VAMC will do my Lap Band. I know that the Doctors at Southwestern Medical School have to practice on somebody?

Pete,

Were you able to confirm whether the Dallas VAMC will implant the lapband?

[Pete53 0]

Randi:

Not yet but working on it. Next week I plan to visit Fee Service to see what they say about paying my co-pay as it looks like my Secure Horizons Medicare HMO is going to OK the surgery. The Doc was supposed to write the letter today and I have a scope scheduled for Sept 13th and waiting for an appointment to get cardiologist to approve me for surgery.

My experience at VA is it takes for ever to get approval so if my Insurance OKs I am going for it even if I have to pay the copays myself.

Anyway, thanks for asking. I wish good fortune for all who are dealing with Tri-Care or the VA.

[Randi 0]

Randi:

Not yet but working on it. Next week I plan to visit Fee Service to see what they say about paying my co-pay as it looks like my Secure Horizons Medicare HMO is going to OK the surgery. The Doc was supposed to write the letter today and I have a scope scheduled for Sept 13th and waiting for an appointment to get cardiologist to approve me for surgery.

My experience at VA is it takes for ever to get approval so if my Insurance OKs I am going for it even if I have to pay the copays myself.

Anyway, thanks for asking. I wish good fortune for all who are dealing with Tri-Care or the VA.

Pete,

Just make sure that your PCM uses the adjustable gastric band, CPT Code 43770. The lapband also has CPT codes for the fills and the pieces of the device should any portion of it need to replaced. From time-to-time, the insurance company confuses the band procedure with the gastric bypass procedure or one of the other band procedures. So, it's best to tell 'em exactly which procedure you want by code so you get a definite approval/disapproval for the surgery you want.

[Pete53 0]

Randi:

Thank you so much. Its wise to make sure all the bases are covered. My Doc says that I will get the Surgery at a Center for Excellance; whatever that means? I am going to request copies of his progress notes and his letter to Insurance.

Pete

[DaniKLargo 0]

Randi -

Thanks so much for the info. I see a long uphill battle ahead. You don't happen to know where we could find out about the changes coming to Tricare, do you? I really don't want to spin my wheels any more than necessary. I googled it, and all I found were articles dealing with the proposed fee changes - nothing about coverage.

Dani

[Randi 0]

Randi -

Thanks so much for the info. I see a long uphill battle ahead. You don't happen to know where we could find out about the changes coming to Tricare, do you? I really don't want to spin my wheels any more than necessary. I googled it, and all I found were articles dealing with the proposed fee changes - nothing about coverage.

Dani

Dani,

The tidbit of information about the contract change in January 2007 was given to me verbally by a Tricare Service Center representative, but I haven't seen it officially published anywhere.

[Randi 0]

Randi:

Thank you so much. Its wise to make sure all the bases are covered. My Doc says that I will get the Surgery at a Center for Excellance; whatever that means? I am going to request copies of his progress notes and his letter to Insurance.

Pete

Pete,

There's only a handful of Centers of Excellence. Here's a link to the current list:

http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp?filterType=none&filterByDID=-99&sortByDID=4&sortOrder=ascending