TRICARE Now Covers ?Lap-Band? Surgery

[Randi 0]

TRICARE Now Covers “Lap-Band” Surgery

January 16, 2008 No. 08-04

FALLS CHURCH, VA. – TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007.

“We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community,” said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. “We’ve added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health.”

Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person’s height and bone structure may also indicate morbid obesity.

In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.

Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online at http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManuals.DisplayManualSeriesInfo&ManualSeries=POLICY&TP02=67#TP02. A search for "morbid obesity" goes directly to the correct section.

About TRICARE Management Activity and the Military Health System

TRICARE Management Activity, the Defense Department activity that administers the health care plan for the uniformed services, retirees and their families, serves more than 9.1 million eligible beneficiaries worldwide in the Military Health System (MHS). The mission of the MHS is to enhance the Department of Defense and national security by providing health support for the full range of military operations. The MHS provides quality medical care through a network of providers, military treatment facilities, medical clinics and dental clinics worldwide.

[chell1957 2]

This is great news! I use the VA myself (Philly Pa) and am hoping to have it done at Pittisburg VA.

[Divamom 1]

You are right on Randi!!!!! As I was denined coverage for surgery in 2006 FEB. I see my doctor this Thursday Jan 24th to discuss my referral. I hope all goes well this time I've been waiting along time for this. I also carry Medicare part A so hospitalization will be covered.

I hope everyone else with Tricare will also get busy out there. But remember you must be morbidly obese

(100 lbs over your ideal weight for height and bone structure) and their weight is associated with severe medical conditions known to have a higher mortality rate.

DIVAMOM Leah

[pta2007 3]

Divamom,

Your info states that you are only 37 years old. How are you able to qualify for medicare A? Just curious.

[mommakatx2 0]

If you search this forum you will see a 5 page thread on this topic. Just FYI

[Randi 0]

Folks,

If you're covered under Tricare, the important thing to remember is that Tricare does not use BMI as their standard for approving the procedure like many insurance carriers. So, if you don't meet the Tricare requirements you still may not be covered for the procedure even though the lapband is now a funded surgical procedure.

When I get a chance, I'll go through my previous posts and repost Tricare requirements in this thread.

[Randi 0]

Folks,

As promised, below is the current Tricare policy as stated in their regulation. I'm assuming the items in red are the most recent changes since CPT 43770 is the procedure code for the lapband. I hope this information proves helpful or at least saves you a little research. Good luck to you all.

TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002

CHAPTER 4 SECTION 13.2, Change 66 dated 12/10/2007; Change 67 dated 12/13/2007

SURGERY FOR MORBID OBESITY

I. CPT PROCEDURE CODES

43644, 43770 - 43774, 43842, 43846, 43848, 43886 - 43888, S2083

II. DESCRIPTION

Morbid obesity means the body weight is 100 pounds over ideal weight for height and bone structure, according to the most current Metropolitan Life Table, and such weight is in association with severe medical conditions known to have higher mortality rates in association with morbid obesity; or, the body weight is 200% or more of ideal weight for height and bone structure.

III. POLICY

A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded gastroplasty is covered when one of the following conditions is met:

1.

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.

2.

The patient is 200

%

or more of the ideal weight for height and bone structure. An

associated medical condition is not required for this category.

3.

The patient has had an intestinal bypass or other surgery for obesity and, because

of complications, requires a second surgery (a takedown).

B. In determining the ideal body weight for morbid obesity using the Metropolitan Life Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the weight range. Payment will be allowed when beneficiaries meet all requirements for morbid obesity surgery including the ideal weight within the newly determined range.

IV. EXCLUSIONS

A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction.

B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of morbid obesity is unproven (CPTprocedure code 43645, 43845, 43847, or 43633).

C. Gastric bubble or balloon for treatment of morbid obesity is unproven.

D. Gastric wrapping/open gastric banding (CPT2 procedure code 43843) for treatment of morbid obesity is unproven.

E. Unlisted CPTprocedure codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and

omentum) for gastric bypass procedures.

V. EFFECTIVE DATES

A. Laparoscopic surgical procedure for gastric bypass and gastric stapling (gastroplasty), including vertical banded gastroplasty are covered, effective December 2, 2004.

B. Laparoscopic adjustable gastric banding is covered, effective February 1, 2007.

- END -

[me722 0]

I just called Tricare and they said that it is definatly covered and that all I need to do is get my primary care to refer me and I can start the process. I am on prime so they will cover 100% since we dont have a military hospital locally. I am so excited I never thought I would get to have this done because it cost so much and I couldnt pay out of pocket. It actually may happen assuming alol my madical checks come back correct. I just hope my doctor will refer me. My BMI qaulifies me it is 49 so all I need basically is to pass my blood test YAY......

[Kathie719 0]

I had surgery 11/26/07. I have another insurance alone with Tri Care. So far every bill is not in but will let you know what they pay. Hopefully all that my other insurance does not.

k

[Randi 0]

I just called Tricare and they said that it is definatly covered and that all I need to do is get my primary care to refer me and I can start the process. I am on prime so they will cover 100% since we dont have a military hospital locally. I am so excited I never thought I would get to have this done because it cost so much and I couldnt pay out of pocket. It actually may happen assuming alol my madical checks come back correct. I just hope my doctor will refer me. My BMI qaulifies me it is 49 so all I need basically is to pass my blood test YAY......

Tricare uses POUNDS not BMI to determine eligibility. Hopefully, your BMI of 49 puts you in the weight range for coverage.

[me722 0]

I am not sure exactly what weight at which they consider but I am 5'5 and 301 pounds at 21 years old. With history of every obese related illness in my complete family. I am going to make an appt with my primary care this week in see what happens. I have been battling this for years. I have known people to have it done at way less. Does anyone know the answer to this?

[Randi 0]

I am not sure exactly what weight at which they consider but I am 5'5 and 301 pounds at 21 years old. With history of every obese related illness in my complete family. I am going to make an appt with my primary care this week in see what happens. I have been battling this for years. I have known people to have it done at way less. Does anyone know the answer to this?

You'll find that those who have been banded at lower weights are usually self-payers or qualify because they have a lower BMI with existing comorbidities. However, it really boils down to what your insurance policy will cover. Some policies are more stringent than others and require 6 months or more of supervised/documented diet and excercise before weight loss surgery will be approved.

[michellepom 0]

I was approved this month by Tricare. I did not do a weight loss program. The only thing they had me do (besides the regular psych eval and what my surgeon's office had me do) was an upper GI.

For my comorbid I had joint pain and my liver enzymes were off. I was approved right away.

BUT BE AWARE, MOST OF THE REPS AT TRICARE DO NOT KNOW YET THAT THIS IS A COVERED PROCEDURE. Everytime I call I get transfered about 4 times before I finally get a hold of someone who knows what they are talking about over there. I still haven't gotten good answers about how to do my follow up fills. I'm sure they will fix the glitches, but they need some serious education over there at Tricare North.

Michelle

[Randi 0]

I was approved this month by Tricare. I did not do a weight loss program. The only thing they had me do (besides the regular psych eval and what my surgeon's office had me do) was an upper GI.

For my comorbid I had joint pain and my liver enzymes were off. I was approved right away.

BUT BE AWARE, MOST OF THE REPS AT TRICARE DO NOT KNOW YET THAT THIS IS A COVERED PROCEDURE. Everytime I call I get transfered about 4 times before I finally get a hold of someone who knows what they are talking about over there. I still haven't gotten good answers about how to do my follow up fills. I'm sure they will fix the glitches, but they need some serious education over there at Tricare North.

Michelle

Michelle,

I went to my surgeon's office today and was told I would have to get a referral from my PCM requesting authorization from Tricare for four visits over the next few months. The explanation I was given is that the surgeon's office can't bill unless the visits are authorized. Without that prior authorization, I'm on the hook for the bill.

It just so happens that I have an appointment with my PCM in the a.m. So, I'll get to see first-hand how well this is going to work and post what I find out. My plan is to take a copy of the new Tricare policy with me to help things along and avoid the run-around.

[me722 0]

Randi tricare did tell me my PCM was the only way I could get to a surgeon and not have to pay for it. So I called at 830 this morning and had one set up. I go the 31st of the month to start the process.

I am a little worried though I have been under weight loss care by my pre military doctor then when I got married went to the only thing that tricare covered in the southeast a nutritionist who says you should go on a diet (DUH dont you think i have tried that) but all of that happended with my old PCM. The new one has only treated me for a cold......

I have also not had any problems getting my questions answered through tricare maybe I am just lucking out. Everyone I have talked to has known about the coverage and has been more than happy to answer an question. I am in tricare south. I am calling back in the morning to see exactly what I need to have done pre-op wise to get approved.

I wish everyone luck and am scared but excitied at the same time.