Tricare

[orrn 0]

This is so frustrating to hear!!! They will, they won't!! All I know is I started with getting my info from Tricare and they told me the steps to take. 5 days left for them to contact me.......I can only wonder. Will keep you posted.

[orrn 0]

Very interesting!!! I just received my authorization letter to see a surgeon. I will call in the am to see what I need to do now.

[lisawynita 0]

If I was you I would call Tricare. I had a referal to see a dr to get my fills when I moved here to Kansas and I went to see him and then when it came to pay for my fills they told me it was a non-covered procedure because the lap band was not a proven weight loss method. So now I have to pay for my fills. If you are close to Walter Reed or Fort Belvoir I know they do the lap bands at those hospitals and the Dr. are great. If you want I can get the numbers for you if the Tricare thing doesn't work out.

[stacyann39 0]

Hello all...I had a quick question about tricare compared to other insurance co's coverage for this procedure. I am enaged to a retired Navy man and will be covered with tricare after we are married. We live in kansas and will do all doctoring in Leavenworth. I currently do not have any type of insurance on just myself and was wondering if it would be worth it to just go to an outside company such as blue cross etc..and pay out of pocket premiums for myself or go ahead and get the tricare in hopes that one day they will cover this surgery. Also, is there anything I should be doing this early in the game to get prepared example, food journal for doc to go over, etc.I know I will h ave a new doc after I am on my husbands insurance if I decide to be..I am not on any medications except for Migraine meds, have never been on a medically supervised diet or have never been diagnosed with any weight issue diseases, at least not yet...I am just tired of the yo-yo dieting and am sure the heart, diabetic, BP issues are sure to come if they have not already. 9 ( have not been to a doc in years except for headaches and he just says to watch my fat grams regarding my weight...grrrrr)Thanks for any help and God Bless...

[lexysmommy 0]

Very interesting!!! I just received my authorization letter to see a surgeon. I will call in the am to see what I need to do now.

I went through this process with Tricare last year. Got the referral and the appt with the surgeon. But when the surgeon put in for the pre-authorization Tricare denied it, saying it wasn't covered. I still don't understand why the even sent me to him.

I hope things work out much better for you! :clap2:

[lefty 0]

Tricare had a change come out dated 8/30/06 that INCLUDES LapBand and FILLS. It is not listed in their handbook (yet), but some people across the country are saying that Tricare IS covering their lapbands. I think the major roadblock is what CPT code your surgeon is using. For instance, mine uses 43770 (which is a covered CPT), whereas, I see on other surgeons websites, they use various other CPT's (for instance, CPT 43999).

I found this transmittal on the web when I was doing my research. When talking with the people at Tricare, you might want to mention this transmittal that also includes fills.

Please remember, that WLS of ANY kind with Tricare needs to be PREAPPROVED (unless you have OHI) (then it goes by their rules).

Anyhow, I will try to paste it on here, but if it doesn't come through, I will also paste the web address for it AND the changes for the CPT codes from the FACS that show the codes for banding and fills that ARE COVERED by Tricare per this portion of the transmittal:

II. PROCEDURE CODE(S) 43644, 43770-43774 (these are the ones for LB and Fills) :clap2: , 43842-43843, 43846, 43848 and 43886-43888

So first the web addresses:

http://www.facs.org/fellows_info/bulletin/2006/bothe0106.pdf

The document is copy protected, BUT what you need to know is at the bottom of page 2, starting at the left hand side.

The address for Tricare changes is:

http://www.va.gov/hac/forbeneficiaries/champva/policymanual/cvapmchap2/1c2s29.15.pdf

TRANSMITTAL #: 95 DATE:08/30/2006 TRICARE CHANGE #: C-42/43 2-29.15-1 CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 29.15

TITLE: SURGERY FOR MORBID OBESITY

AUTHORITY: 38 CFR 17.270(a) and 17.272(a)(22)

RELATED AUTHORITY: 32 CFR 199.4(e)(15)

I. EFFECTIVE DATE

November 9, 1982

II. PROCEDURE CODE(S)

43644, 43770-43774, 43842-43843, 43846, 43848 and 43886-43888

III. DESCRIPTIONS

A. Morbid obesity is defined as a body weight 100 pounds over ideal weight for height and bone structure.

B. Bariatric surgery. Surgery for morbid obesity produces weight loss by either limiting the amount of food the stomach can hold (a restrictive procedure), or by creating a small pouch and bypassing part of the small intestine to limit the food hat is absorbed by the body (a gastric bypass).

IV. POLICY

A. CHAMPVA benefits for surgery for morbid obesity is limited to:

1. VBG (Vertical Banded Gastroplasty) or gastric stapling, without gastric bypass, (CPT 43842) this is an open procedure

2. Gastric restrictive procedure, without gastric bypass, other than vertical banded gastroplasty

3. Gastric restrictive procedure, with gastric bypass; with short limb (less than 150-cm) Roux-en-Y gastrojejunostomy (CPT 43644 laproscopic, or CPT 43846 open approach)

TRANSMITTAL #: 95 DATE:08/30/2006 TRICARE CHANGE #: C-42/43 2-29.15-2

4. Adjustable silicone gastric banding (CPT 43843) using the FDA (Food and Drug Administration) approved LAP-BAND® Adjustable Gastric Banding (open or laparoscopic procedure); for severely obese adult patients who have failed more conservative weight-reduction alternatives, such as supervised studies, exercise and behavior modification programs. The LAP-BAND system is contraindicated in patients with any of the medical conditions listed under Policy Considerations as well as patients under 18 years of age.

5. Revision of gastric restrictive procedure for morbid obesity (CPT 43848)

B. Surgery benefits for morbid obesity may be extended only when one of the following conditions is met:

1. BMI is over 40

2. BMI over 35 with a serious medical condition associated with obesity, that is, hypertension, Type ll Diabetes Mellitus, severe arthritis of weight bearing joints

3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown). The surgeon will, in many cases, do a gastric bypass, gastric stapling or gastroplasty at the same time as the takedown to help the patient avoid regaining the weight that was lost. In this situation, payment is authorized even though the patient's condition may not technically meet the definition of morbid obesity because of the weight that was already lost following the initial surgery.

C. Each claim related to the surgical treatment of morbid obesity will be medically reviewed to ensure that documentation supports the medical necessity and appropriateness of the surgical procedure. When necessary, additional clinical documentation will be requested.

D. The surgery is an integral and necessary part of a course of treatment for a patient with one of the following life threatening or disabling co-morbid conditions:

1. Poorly controlled type II diabetes mellitus

2. Poorly controlled dyslipidermia

3. Poorly controlled hypertension

4. Serious cardiopulmonary disorder, such as coronary artery disease, cardiomyopathy, pulmonary hypertension)

5. Obstructive sleep apnea

6. Severe arthoplasty or weight-bearing joints (treatable but for the obesity)

7. Pseudotumor cerebri

TRANSMITTAL #: 95 DATE:08/30/2006 TRICARE CHANGE #: C-42/43 2-29.15-3

VI. EXCLUSIONS

A. Payment may not be made for non-surgical treatment of:

1. Obesity

2. Morbid obesity

V. POLICY CONSIDERATIONS

A. Even though the beneficiary may meet the morbid obesity criteria, gastric procedures are usually contraindicated when any of the conditions listed below are present. Cases in these groups shall not be categorically excluded. Review of the medical circumstances and medical appropriateness will be performed. If the documentation does not support the medical appropriateness of the surgery, the claim will be denied.

1. Active hepatitis

2. Chronic alcoholism

3. Cirrhosis of the liver

4. Dental disease

5. History of anorexia nervosa, bulimia or related eating disorder

6. Infection, particularly in the skin or elsewhere in the body

7. Inflammatory bowel disease

8. Malignant tumors

9. Mental retardation

10. Organic brain syndrome

11. Profound psychotic disturbance

12. Pulmonary embolization

13. Renal failure

B. CHAMPVA will cover procedures that are medically necessary to correct skin complications, such as severe intertrigo, skin chafing, pain, abrasions, pockets of superficial ulceration, or scar revision, which may occur as a result of approved surgery for morbid obesity.

TRANSMITTAL #: 95 DATE:08/30/2006 TRICARE CHANGE #: C-42/43 2-29.15-4

E. Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption (CPT procedure code 43847).

3. Dietary control

4. Weight reduction

B. Biliopancreatic bypass (jejunoileal bypass, the Scopinaro procedure) CPT procedure codes 43633, 43645, 43845, or 43847.

C. Mini-gastric bypass (gastric bypass using a Billroth II type of anastomosis).

D. Gastric balloon or bubble for treatment of morbid obesity.

F. Unlisted CPT procedure codes 43659 (laparoscopy procedure, stomach); partial biliopancreatic bypass (with or without duodenal switch) 43999; and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

G. Prescription medications used for weight reduction [38 CFR 17.272(a)(22)]

H. Services and supplies in connection with cosmetic surgery that is performed to primarily improve physical appearance or for psychological purposes or to restore form without correcting or materially improving a bodily function [38 CFR 17.272(a) (19)(78)]

I. Weight reduction clinics, programs, or health club memberships [38 CFR 17.272(a)(37)]

J. Laparoscopy, surgical, gastric restrictive procedure with gastric bypass and small intestine reconstruction to limit absorption (CPT procedure code 43645).

*END OF POLICY*

[lefty 0]

OKAY, SOOO sorry for confusion. THIS IS for CHAMPVA folks.

Now I feel REALLY stupid.........But, seems like we should really push for TRICARE to adopt this, too. I mean, how much money can they be saving with the complications from RNY??

Cathy

[lisawynita 0]

I was told by Tricare that lap bands and the fills for them are not coverd because they are unproven. I am now paying for my fill myself. You would think that if the military does the surgery then Tricare woyuld have to provide the medical care and up keep of the band. But it seems we are caugt in a catch 22. Has anyone had the sugery or fills done by Tricare?

[lefty 0]

You know, after realizing my error last night, I checked the Tricare policy manual and they definately list lapband as an exclusion . :think ( them dogs) I'm still gonna try to file a claim with them after my surgery is done through BCBS. (maybe they'll cover some of the remaining bill.) And then again, maybe they'll realize that the procedure has gone past being 'experimental'.

Cathy

[gingersnap 11]

Tricare stopped covering LapBand in 2004 due to "effectiviness" and longterm result concerns. I can't see them changing their policy anytime soon. But wouldn't it be great if they did! I'll keep my fingers crossed.

I still plan to submit a plea for coverage.

[lisawynita 0]

I do not know where you live but I know that Walter Reed and Fort Belvoir will do the lapband. Dr. Ryan at Fort Belvoir is great and very caring. The Dr that did mine at Walter Reed has left the Army. Does any one know if there is a doctor at Fort Sill that does the fills? They train these Docs at Walter Reed so you would think that the doc would be sent to other post and could do fills. Or am I just thinking outside the box. Thanks for the info.

[Boo Boo Kitty 3]

OKAY, SOOO sorry for confusion. THIS IS for CHAMPVA folks.

Now I feel REALLY stupid.........But, seems like we should really push for TRICARE to adopt this, too. I mean, how much money can they be saving with the complications from RNY??

Cathy

I absolutely agree. I have ChampVA so we got lucky....all the bills are sent to the same spot, no idea why Tri Care is not the same. Good luck to all of you!

[Sissy907 1]

<p>Hi everyone! I too am a military wife stationed at Hurlburt/Eglin having the exact same issues with getting the lapband. I also have a surgeon (on base) that is very pro GB but very down on the band. After finally getting all my test results back and finding out I do qualify with a lower bmi I asked him yesterday to send my information to Walter Reed. He is but he wont put his seal of approval on it as I also have severe reflux with a hiatal hernia. (which I think will be much better once fixed and the weight is gone) But whatever all doctors are different and I want to talk to the guys up at Walter Reed to see if they will do this surgery for me. I think my surgeon was kind of stunned that I knew that they do the band up at WR. I dont think he expected me to have done so much digging. I dont think he fully understands me when I say I have done my homework and researched these surgeries, even watching some live. Maybe he has heard it to many times and some really dont. I did, and I could throw statistics back a him and quote studies and he seeme to change his tune and said he would be happy to send my consult in today. I am keeping my fingers crossed the guys at Walter Reed are in the mood for some surgery soon!</p> <p> </p> <p>I wonder if we as a group couldnt find as many lap-bandies in the military as we can and approach our respective TriCare offices and demand that these surgeries/fills be covered. Give them our own statistics based on our cases. Yeah loosing the weight is slower in the begining, but for those of us that want to work hard for what we get, this is the road for us and we should be allowed to choose what we want done to our bodies instead of being forced into letting them pad thier resumes with chopping our guts up. Thoughts?</p>

[pholdennp 0]

hi, tricare told me they would only pay for GB- my surgeon also does lapband and gb= - do you have any inof on how i could get a referral for lapband instead?

[pholdennp 0]

hi, pls pls tell me how to get lap band at walter reed? I'm close to both there and ft. belvoir, but have not had any success yet!

fills are pretty affordable right? If not, do they do them at ft. riley or Levenworth?