Insurance doesn't cover gastric sleeve

[foodfighter78 258]

Hello after many months of preparations, dieting etc my surgeon submit papers for surgery request, insurance denied, I call insurance and they told me it's because it's missing clinical note, surgeon told me it's because my insurance doesn't cover gastric sleeve. Only lap bad and gastric bypass. I have military tricare west. Any person here has same problem? Should I do the bypass instead? I think sleeve is less invasive.

[Eclectick 129]

Hi Foodfighter,

As per my research, I could be wrong but your insurance covers Gastroplasty (stomach stapling) which I believe is the same thing? No?

[foodfighter78 258]

They don't cover laparoscopy surgical gastric restrictive procedure; latitudinal gastrectomy ( from their letter I just got today)

[LouiseandThelma 8]

Are you close to a Military Hospital? You would have to have Tricare Prime to use the Military Treatment Facility, but they do the sleeve. Its worth it to check out. I ran into the same problem in Maryland and found out too late that I could change over to Tricare Prime and have it done at a MTF. We have since transferred and I am just now starting over again. I hope this helps.

[foodfighter78 258]

I have prime, unfortunally the next military clinic is in San Diego and I'm about 4 hrs away from it.

[LouiseandThelma 8]

I am driving from Key West to Jacksonville 9 hours one way. Since this is elective surgery for me Tricare will not cover my travel expense. If I have to pay out of pocket for a self pay it's 10,000 -12,000 in Miami. The doctor I saw on Friday was pushing the band, which is covered by Tricare and I could be referred out. So if I have to do the drive it's worth it to have the sleeve.

[foodfighter78 258]

Good point, but what about visit or emergency problems etc. you will have to drive 9 hrs to get taking care for it? I can't pay out of pocket, I'll have to go with gastric bypass

[LouiseandThelma 8]

I called and talked to Tricare and in the case of emergency I go to the nearest ER and I'm covered. I live in Key West so any major medical care for us is 3 to 4 hours up the road in Miami. I understand what you are saying and I have thought about it.

[foodfighter78 258]

Today I talk to my surgeon and he said he is going to appeal at the insurance decision to cover the sleeve. He said he will personally call and show them several studies about the efficiency of the sleeve. Off course he told me that might be a long process, but he was saying that medical and Medicare did lots of research etc anyways let's keep finger cross that I can do the sleeve. We both think would be the best surgery for me. Did anyways ever appeal to insurance?

[denden2brn 1]

Yes I was denied also but because they said I didn't have 2yrs of weights. Thank goodness my diabetic doctor did! Got it overturned and 5 months pre-op and 54 lbs down!! Off all meds! Good luck to you and keep fighting them!! Feeling great in Tampa!

[Jenny Eisenberg 0]

Are you close to a Military Hospital? You would have to have Tricare Prime to use the Military Treatment Facility, but they do the sleeve. Its worth it to check out. I ran into the same problem in Maryland and found out too late that I could change over to Tricare Prime and have it done at a MTF. We have since transferred and I am just now starting over again. I hope this helps.

That is the best news I've heard! I was having the same problem here in Delaware, however, I live a short 20 minutes from our VA hospital and we have Tricare Prime! Should I consult with a gastroenterologist? If not, which specialty would this fall under?

[LouiseandThelma 8]

Jenny Eisnberg,

I just got into the program in Jacksonville. You have to go to your PC doctor and tell them you want a referral with General Surgery for a Bariatric consul. Do you know if the VA clinic you are close to has a Bariatric program or does the surgeries? That would be your first step, just incase your PC doesn't want to send you. Also Tricare Prime will tell you it isn't a covered service. ITS NOT if you go on the outside. You have to have the sleeve at a MTF.