Tricare North, co-morbidities, and Fort Bragg

[BjSkyGGEvan 0]

I am new to this forum and am thrilled that I found it. I just found out a couple of days ago that Tricare will cover lap band and am thrilled but don't think I will qualify. I am hoping maybe you guys can give me some guidance based on your experiences. I am 5'5 and 100 pounds overweight. My concern is the co-morbidities that Tricare requires. I already had asthma but now it is worse. I can actually be doing something and catch myself gasping for air. I can't speak more than 10 words without losing my breath. My husband tells me I snore (loudly) which I never did before. I have woken up catching myself trying to catch my breath. I have knee pain and it kills my feet to walk. I have severe back pain and my choloesterol is up and down. Right now it is at 199 but if it goes up 1 point, then I have high cholesterol. I have syptoms that fall under hypothalamus problems but don't know if it is coincidence or because of my weight. My blood pressure isn't exactly great either. My husband is active duty at Fort Bragg and they do have a bariatrics clinic at the hospital, however I don't know if they do the lap band or not since when I looked into the clinich, lap band wasn't approved. So if anyone has any experience with Tricare North, Womack, and what co-morbidities can be used to get approved I would really appreciate your input. I have read the basic information but I don't have diabetes, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, or severe arthritis. My PCM is a civilian doctor and I don't think it will be a problem getting the freferral as my doc knows I have been struggling with my weight for a very long time.

Thanks for any help you can give me.

[KayleighsMommy 16]

I'm no expert... but it sounds like you probably have sleep apnea, which is usually a comorbidity, as well as High Blood pressure and highish cholesterol. At 100 pounds overweight, you most likely (I'd say definetly) have a high enough body mass index. Have you looked at the insurance website to see if there is any info on what is needed??

Sorry I can't be more help.

julie

[BjSkyGGEvan 0]

From what I have been reading, Tricare doesn't care about BMI which is a bummer because mine is right at 40.

[Long2BFree 12]

Go to the Tricare office and talk to them. They should have a list of doctors in your office and tell you which military facilities in your area cover the procedure. Lapband was approved starting in Feb 08 with Tricare.

Good luck!

[AZChick289 1]

Hi there BJ,,

It sounds like you would qualify for the lap band. I just got apporved from TirCare West.

Your civilian Dr is the one who can really get you going not the military clinic... The Dr can refer you then the bariatric surgeous will run you through a barrage of tests that will confirm if you qualify or not.. It really does sound like you have sleep apnea and they will test you for that also.. Tricare will pay for all the testing .Also with a caridiologist too ... You have to try and I think you will be pleasantly surprised. Oh and once they send in the info Tricare is very fast at approval ..So get out there and give it all you got and we will be waiting to see how you do .....

[Lori in Cali 0]

http://www.cmcwls.com/insurance.php

A patient is 100 pounds or more over ideal weight for height and body 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.

A patient is 200% or more of the ideal weight for height and body structure. An associated medical condition is not required for this category.

A patient has complications from a non-covered surgical treatment for obesity, such as intestinal bypass, and needs one of the three surgical procedures that are covered.

Tricare Standard does not cover any others services, medications, or supplies related to obesity or weightreduction. Non-surgical treatment of morbid obesity, such as wiring the jaws, camps for obesity treatment,or special diets, are not covered.

Gastric bypass procedure is covered, Lap Band procedure is not covered.

And hypertension is high blood pressure. If you're doing loud, ugly moose snoring where you can't breathe, that is sleep apnea. If they turn your down, call the Obesity Law Center and get their help. Call 'em even you think you can't afford it. They work hard at making themselves affordable for us working class types.

http://www.obesitylaw.com/

[AZChick289 1]

I do know that TriCare Prime does cover lap band procedure as I just had mine approved and am having the surgery the end of the month.

A new law was passed and Tricare approves both Lap band and Bypass ..

Best to call the tricare office and find out what is covered ...This new law was passed Feb 08..

[minpinmom 2]

Sorry this didn't format very well. Tricare started covering Lapband Dec. 10, 2007. They backdated it to Feb 2007 (I believe). This is taken directly off of their website. I had surgery Feb 19th of this year, covered 100% by Tricare. Good Luck! (Oh, I put the important stuff in RED)

TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002

SURGERY

C-66, December 10, 2007

CHAPTER 4

SECTION 13.2

SURGERY FOR MORBID OBESITY

ISSUE DATE: November 9, 1982

AUTHORITY: 32 CFR 199.4(e)(15)

I. CPT1 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.

TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002

CHAPTER 4, SECTION 13.2

SURGERY FOR MORBID OBESITY

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 (CPT2 procedure 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 CPT2 procedure codes 43659 (laparoscopy procedure, stomach); 43999 (open procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and omentum) for gastric bypass procedures.

F. Adjustable gastric band (open or laparoscopically) (CPT2 procedure codes 43770 -43774, 43886 - 43888, and 90772).

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. Laproscopic adjustable gastric banding is covered, effective February 1, 2007.

C-66, December 10, 2007