Tricare - does is, or does it not

[bigal62 0]

You are correct, they cover both

Today I was on the Tricare West website & I looked up coverage for this & this is what I got:

Gastric Bypass

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
  
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity

Can someone correct me if I'm wrong, but I read here that Tricare covers both surgeries.....Gastric & Lapband????

[moosey52 0]

Hello everyone, well Monday March the 10th I got my approval from Tricare standard. My husband got his military retirement for putting in 20yrs with the Ky. National Guardsmen. Now my Dr. and Hospital are in Tricare network so that`s when you get Tricare Extra, which helps because I still will have to pay something but not as much. They told me approx 2400. If you can get a letter from your primary care Dr. before setting up a appointment with a surgeon then you will be one step ahead when you walk through that door. I had the Tricare Regional Office North, and they really help me along. This is what it saids

Gastric Bypass (Surgery for morbid obesity) – Limited Benefit – Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty may be covered when one of the following conditions are met (view Hospitalization Costs):

• The patient is 100 pounds over the ideal weight for height and bone structure and has an associated medical condition, such as 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, regardless of associated medical conditions.
  
• Laparoscopic adjustable gastric banding is covered, effective February 1, 2007.
  
• The following are not covered:
  • Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633).
    
  • Gastric bubble or balloon
    
  • Gastric wrapping/open gastric banding (CPT code 43843)
    
  • Unlisted CPT codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum and omentum).

So I`m sure you will qualify with one of these. Try these sites also. https://www.hnfs.net/provider/home/

https://www.hnfs.net/bene/home/

Good Luck and let me know how you do....

[4Aria 0]

I was approved with tricare prime.

[tyrind 0]

hello. i am new this forum. i just have aquestion for anyone with bcbs of michican. i have not went through all the steps yet just sent in all of my paper work. but i called my insurans company and they do pay for the lapband but they do not do a pre approval. they say they will send a letter stating what the requirements are and if my requirement meets that then it will pay. well when i talked with the lady that does all of that work she said when they send it in after i have the surgery & they don't pay then it will be my responsibility! i really don't want that to happen! can someone please tell me something!!!!

[tyrind 0]

hello. i am new this forum. i just have aquestion for anyone with bcbs of michican. i have not went through all the steps yet just sent in all of my paper work. but i called my insurans company and they do pay for the lapband but they do not do a pre approval. they say they will send a letter stating what the requirements are and if my requirement meets that then it will pay. well when i talked with the lady that does all of that work she said when they send it in after i have the surgery & they don't pay then it will be my responsibility! i really don't want that to happen! can someone please tell me something!!!!

[DebbieG 0]

Hello - this is my first post ever; and it is going to be a long one!

I have been overweight since I hit puberty and now I am menopausal! I was active duty Navy myself and then got married to a sailor. I have 3 grown children and now two grandchildren. I was a stay-at-home Mom until we "retired" and I got a job. Then he got a midlife crisis and now I am living alone. However, I retained all my military base rights because we had been married so very long - over 25 years.

I was diagnosed as becoming diabetic and put on the counting calories diet...again. I lost 30 pounds in 2005...by the end of 2006 I had gained it all back and more... and more again in 2007.

I live near Wright Patterson Air Force Base in Ohio and I use it as my only medical source.

At Easter in 2007 I had to go to a 5X size...so at my appoinment with my provider in early May I said - what NOW!!!!! I lose, I gain, I lose, I gain - I can't take anymore!!!! He said - I will send you to see the bariatric surgeon.

In less than two weeks I was scheduled to attend a "lecture" with several other prospective surgery candidates and we were told to:

1. Get a bunch of blood tests taken

2. Make an appointment with the Mental Health clinic

3. Attend a Group Session

4. See a nutritionist

5. See the surgeon.

Since my son is in the Army and was home visiting the last weekend of May that year, I missed the group session in May, they are only on the last Thursday of the month. I got all my other appointments done and attended the group session at the end of June. (my son is currently on his 3rd deployment to Iraq)

They had a cancellation and I was able to see the surgeon, Major Dock, the very next Monday! After talking with him; I agreed, he agreed and he looked in his book.....there was a cancellation and would I want to have the surgery on July 10th - the very next week!!!!!!

I weighed 280 pounds and am 5 foot 8 inches tall....not taking meds for diabetes; but considered to have it; have a family history of cholesterol and heart disease.

I went home the day after the surgery - slight swelling, minor pain and stayed home from work for the first 2 weeks...but after 2 days I was working 1/2 to full days from home on the computer.

Because of the diabetes, my levels were up and down that first week due to only eating the Clear liquids...I had absolutely no other problems, so he let me begin mushies after the first week. I was able to begin solid foods before the end of the 6 weeks.

He put in 2 ccs - no problems

He put in 2 more ccs and I "had restriction" meaning I was not able to keep down ground meat and even threw up some milk! So he took out 1 cc.

Therefore I have a total of 3 ccs in my band.

During Christmas and my busy time at work I ate what you may consider "inappropriate foods" so my weight loss slowed from more than 2 pounds a week to one pound a week.

To date I have lost 56 pounds.

The only cost I got from the base was fourteen dollars and some cents for the "food" from the hospital stay overnight...OK, I had two glasses of Crystal Light....hello!!!!!

I think the problems you are having is because apparently you are not actually using a base, but just the coverage as normal "medical insurance." I am fortunate that I can use the base and do not have to deal with providers being in-network, co-pays or deductibles or any of those things!!!

I had a very easy time with the surgery and no problems whatsoever. I would highly recommend it to anyone as an option - a much better option than the other surgeries; gastric bypass is not the only other option...but they seem so drastic and I've known people who have had no real problems, and people with horrible problems!!!

Good luck to you!

[Relovlee 0]

Hi im an airforce wifey and army brat also...ho has your recovery been?

[DebbieG 0]

Hi

I am still trouble free, I have had no complications.

Now, though, I have hit a plateau; I have lost a total of 64 pounds, it has been a year since the surgery. I am down to losing about 2 pounds per month.

I have not decided yet if I want to try adding another cc to the band. Or just up my exercise level.

Did you ever get approved?

[pj_txlady 0]

My husband is retired Air Force. My blood pressure started getting very high the last part of April. My husband sent for a list of Dr's that take Champus Ins. My first appt. was with Dr Smith May 7th, I got Champus approval on May 14th. The Drs office took care of contacting Ins. and getting it approved. My surgery date is in 2 days ( Aug 4th). I have Champus Standard Ins....not Tricare.

[Divamom 1]

Are you Tricare Prime? My DH is Air Force and I just had the surgery on June 16th and they paid 100%. I did not even have a co-pay, deductible or anything. We are Tricare West and stationed at Travis AFB in California. But as mentioned in other posts you must be 100 lbs over your ideal weight with a co-morbidity or 200% over your ideal weight. I was 304lbs with diabetes, high blood pressure, sleep apnea, and just doggone tired joints from carrying myself around. I am now 279lbs and have been off all meds for diabetes and high blood pressure since 2 weeks post-op.

Good luck with your journey and I would be glad to answer any of your questions. Take Care, Leah

[katinafer 0]

I am new to the forum but haven't had too much trouble with Tricare it is the physicans and hospital in the area. We are retired military and live in the upstate of SC. The doctors or should I say insurance person(Tricare in network doctor) that do the lapband in our area did not want to believe that Tricare now covers lapband. Once we got our service rep to talk to them, then they wanted to make sure the hospital would take Tricare (out of network hospital). The doctor's office sent the hospital the information. So we have had to wait approx. three weeks and after trying to get this all straightened out, (we thought) we got a call from the insurance person at the doctor's office telling us the hospital is not going to let me have the surgery there because Tricare does not pay enough. They said the lapband itself costs $3800.00 and Tricare only pays $900.00 and that is not including everything else the hospital charges. Has anyone had any luck getting the lapband done in Tricare South?

RJohns,

I too am in SC...Columbia to be exact. I have TriCare Prime and so far, everything has gone smoothly. I am seeing Drs. Tribble & Prickett at Palmetto Baptist Weight Mgmt. Center in Columbia, they are a Center of Excellence, they have been great and I've only heard great things about them. I get to go tomorrow to meet with the surgeon and my surgery is scheduled for Aug 18th (pending TriCare Approval). I'm not sure how far away from Columbia you are but I know that their are people that use this facility and are driving from as far as Myrtle Beach and Dillon so, it may be worth a try for you to switch Doctors.

[fsherald 0]

HOPE THIS INFO HELPS FOR TRICARE INS!

Go to the TRICARE website at www.tricare.osd.mil/

standardprovider to locate a provider in your area

(South Region)

TRICARE covers most inpatient and outpatient care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. This section provides details about services that TRICARE covers, limits and excludes. This is a guide to your TRICARE coverage - it isn't all-inclusive. Some services or treatments require prior authorization. Your coverage and out-of-pocket costs are dependent on your eligibility as a TRICARE beneficiary and may vary according to the program option you're using. Contact your regional contractor or TRICARE Area Office for more information.

Gastric Bypass

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)
  

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
  
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity
  

Last Modified: March 24, 2008