Ok, now I'm a bit freaked out

[Dave_NW 92]

After waiting a looong time to get in, (like three months), I finally went to my Surgeon's marathon appointment clinic today. I met with the Psych, Physician, Nutritionist, and the Surgeon himself. I passed all evaluations and interviews with flying colors, and everyone said I was a prime candidate for surgery. All was going along great until the Surgeon said, "Um, I think we may have a misunderstanding here. Your insurance does not cover the sleeve."

:scared0::blushing: Say WHAT????? :scared0::scared0::scared0:

I made them go to the Tricare website so I could show them the text that says it's covered. When we tunneled down to the covered services part, and found gastric bypass surgeries, it says:

"TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery)"

When I pointed out the text that says "vertical banded gastroplasty," he said, "That's not the sleeve. That's stomach stapling. Nobody does that anymore."

After a bit more investigation, it seems that when I plugged in those words on a website several months ago, it said those words meant the same thing as vertical sleeve gastrectomy. Apparently, that website was wrong. So it seems I may have been doing a LOT of preliminary work for a procedure my insurance won't cover. Crap.

When I got home I called Tricare and asked for clarification, the person said what's written is what's covered, but that the surgeon's Insurance Coordinator can contact them with documentation to request it be reviewed as a medical necessity. They may cover it, but maybe not.

So my dilemma is this: I'm wide open approved for a lap band or RNY bypass. If you couldn't get the sleeve surgery, which would you choose, and why?

Seriously bummed,

Dave

Edited September 29, 2010 by Dave_NW

[Jane_J 117]

I would choose neither and appeal. Good luck.

Jane x

[Dansha 16]

Ohhh.... Dave so sorry to hear that your insurance might not cover the sleeve. THAT SUCKS BIG TIME!!!!

Please keep us posted with whatever decision you decide. GOOD LUCK!!!

Deb

[LilMissDiva Irene 3,280]

Dave, keep fighting for your sleeve. Lots have to appeal and end up getting what they want down the road. DO NOT GIVE UP!!!!

I wish I could take back these useless scars I received when I got banded. True, everyone needs to make up their own minds on which surgery to get - however, I PERSONALLY will NEVER suggest the lap-band to anyone. Never.

It never once worked for me personally. It was nothing like it was "advertised". In fact when something like that needs to be advertised, I say, "Buyer beware". It's no small thing! It shouldn't be treated as though it is either. Though it didn't cause any major damage to me, I know so many that have had some very serious problems caused by the band. It's reversible in the fact it can be removed, but what it leaves behind WILL be permanent. Please keep that in mind.

In fact, I would look up "complications with lap-band" before considering it. It's pretty scary.

I have no direct or indirect exposure to the Gastric Bypass so I'm not help with that. If someone could get help from it, I say do it. Especially if the person has diabetes, as it cures this ailment immediately.

There is a procedure for everyone, depending on your personal needs.

I hope it works out for you! Please keep us posted!!!

[Tiffykins 672]

Dave, Tricare won't cover VSG outside a MTF. Honestly, I was faced with the same dilemma, and as luck would have it, the MTF near us had 2 surgeons that had performed enough VSGs for my standards, and one of them had removed bands, and converted to RNY so I jumped through the hoops to have my revision at the MTF even though I see a civilian for everything else, and my band surgeon was a civilian with Tricare Prime.

Tricare will not cover the sleeve outside a MTF until Medicare starts fully covering the sleeve. They did the same thing with bands.

They will not overturn a denial, they will not do anything to cover the sleeve outside a MTF. I've been through it myself, and I've walked 4 friends through the process from Florida, DC, and Cali. I was hellbent on getting the sleeve, and I would have self-paid with Dr. Aceves in Mexicali or Dr. Nicholson in Dallas if Tricare would have not approved my revision.

If I would not have been able to have VSG and self pay was an absolute no go, I would have had my band removed and stayed fat. I wouldn't get RNY if you paid me, and I refused to have another band placed even though both of those options were immediately approved without hesitation by Tricare.

I'm sorry to be the bearer of more bad news. BUT, it's been "hinted" that Medicare "might" start covering VSG around 1/1/2011, we "heard" the same thing in 2009, but I have hope that Medicare will get on the ball, and Tricare will follow suit.

If there is an MTF near you, check them out. I'll help you in any possible way I can with the Tricare situation. I'm an insurance agent as well, and umm pretty much know how to work the system. Keep all your paperwork from your current appointments, keep getting your PCP to weigh you, keep doing everything you have been doing.

Do not settle for a surgery you are not 100% about.

[chilo1 62]

Dave so sorry to hear this. But I agree w Tiff that you should not settle for a procedure you're not 100% happy with, I wish you the best!

[Dave_NW 92]

Thanks, Ladies. Your support is great. I've been doing a bit more research:

I called the Insurance Coordinator at the Surgeon's office, and had a long talk with her. She was pretty frank with me, and said she works closely with all insurance companies, so she's pretty much on top of things. (The surgeon calls her his "Pit Bull.") She said Tricare is very strict on what they will or won't cover. She said they follow a Governmental list of procedures they will and won't pay for, and if it's not on the list, Tricare won't pay. She gave me the CPT code for the sleeve, and said I should call Tricare and ask them specifically about it.

So I did. And Tricare said the CPT code, (it's 43775, if you ever need to know it), is named on the "Government Not Authorized" list. I asked about appeals on basis of medical necessity, and the woman said, "If it's not on the authorized list, they won't pay. Sorry." I asked about appeals, and she said, "Not gonna happen. The list is the list."

So I asked her about what Tiffy said, about having surgery at a Military Treatment Facility. Since I'm retired Navy, I have benefits there, too, that are separate from Tricare insurance. The Tricare woman said, "You can call them and ask; they may do it. It's separate from what Tricare does."

So I checked out the two military hospitals in my state. One doesn't do anything regarding weight loss surgeries. They were quite specific about that. The other one, Madigan Army Hospital, (a HUGE place), does do weight loss surgeries, but only bypass surgeries. No sleeves. Dang.

Mexico is looking more appealing all the time...

Stay tuned,

Dave

[GayleSBennett 0]

I have Tricare and just got the sleeve done September 17th. I'm Tricare West. (Which you should be as well since you're in the NW)

I'd keep calling. I went through Madigan hospital in Tacoma, WA and had no issue at all. Can you switch to Madigan hospital?

[Dave_NW 92]

I have Tricare and just got the sleeve done September 17th. I'm Tricare West. (Which you should be as well since you're in the NW)

I'd keep calling. I went through Madigan hospital in Tacoma, WA and had no issue at all. Can you switch to Madigan hospital?

Hmm. Very interesting. I'm Tricare Prime. Are you or spouse Active Duty? I'm a retiree. Tricare told me they don't do anything at Madigan, that it's a Military Treatment Facility, so is handled by the military, not them. Sounds like I need to call Madigan again.

Confusing...

Dave

[GayleSBennett 0]

Dave you REALLY need to call back again to madigan.

I just got the sleeve there by Dr. Sebesta on September 17, 2010. My other friend had hers done on the 13th. They do the sleeve surgery EVERY day.

Here is the general surgery clinic number 253-968-3105. Like I said, my doctor was Dr. Sebesta.

I'm a military spouse - active duty. All I had to do was go to my primary care doctor and ask for a weight loss consult. Next thing I know I am enrolled in classes and four months later I had the surgery.

I would see if you can switch your primary care doctor to madigan and then be assigned to a white, blue, red team. Then ask for the consult. I know its a pain.. but its worth a shot.

But Madigan 100% does sleeves. I'm one of them. =)

[Tiffykins 672]

Thanks, Ladies. Your support is great. I've been doing a bit more research:

I called the Insurance Coordinator at the Surgeon's office, and had a long talk with her. She was pretty frank with me, and said she works closely with all insurance companies, so she's pretty much on top of things. (The surgeon calls her his "Pit Bull.") She said Tricare is very strict on what they will or won't cover. She said they follow a Governmental list of procedures they will and won't pay for, and if it's not on the list, Tricare won't pay. She gave me the CPT code for the sleeve, and said I should call Tricare and ask them specifically about it.

So I did. And Tricare said the CPT code, (it's 43775, if you ever need to know it), is named on the "Government Not Authorized" list. I asked about appeals on basis of medical necessity, and the woman said, "If it's not on the authorized list, they won't pay. Sorry." I asked about appeals, and she said, "Not gonna happen. The list is the list."

So I asked her about what Tiffy said, about having surgery at a Military Treatment Facility. Since I'm retired Navy, I have benefits there, too, that are separate from Tricare insurance. The Tricare woman said, "You can call them and ask; they may do it. It's separate from what Tricare does."

So I checked out the two military hospitals in my state. One doesn't do anything regarding weight loss surgeries. They were quite specific about that. The other one, Madigan Army Hospital, (a HUGE place), does do weight loss surgeries, but only bypass surgeries. No sleeves. Dang.

Mexico is looking more appealing all the time...

Stay tuned,

Dave

Yep, Dave exactly what Gayle said. I have 2 girlfriends that had their sleeves done at Madigan. They do them all the time, and have a fabulous program! ! !

[lamsunshine 2]

Thanks, Ladies. Your support is great. I've been doing a bit more research:

I called the Insurance Coordinator at the Surgeon's office, and had a long talk with her. She was pretty frank with me, and said she works closely with all insurance companies, so she's pretty much on top of things. (The surgeon calls her his "Pit Bull.") She said Tricare is very strict on what they will or won't cover. She said they follow a Governmental list of procedures they will and won't pay for, and if it's not on the list, Tricare won't pay. She gave me the CPT code for the sleeve, and said I should call Tricare and ask them specifically about it.

So I did. And Tricare said the CPT code, (it's 43775, if you ever need to know it), is named on the "Government Not Authorized" list. I asked about appeals on basis of medical necessity, and the woman said, "If it's not on the authorized list, they won't pay. Sorry." I asked about appeals, and she said, "Not gonna happen. The list is the list."

So I asked her about what Tiffy said, about having surgery at a Military Treatment Facility. Since I'm retired Navy, I have benefits there, too, that are separate from Tricare insurance. The Tricare woman said, "You can call them and ask; they may do it. It's separate from what Tricare does."

So I checked out the two military hospitals in my state. One doesn't do anything regarding weight loss surgeries. They were quite specific about that. The other one, Madigan Army Hospital, (a HUGE place), does do weight loss surgeries, but only bypass surgeries. No sleeves. Dang.

Mexico is looking more appealing all the time...

Stay tuned,

Dave

Dave, Have you checked with VA hospitals in your area. I just got my surgery done through the VA I had to travel 8 hours to get it done, but to me it was well worth it. I would even check the VA's in the states that border you to see if they do the sleeve procedure, and if your doctor at VA says the VA does approve them they are wrong, it took me 4 years and several doctors to finally fine a Doctor that cared enough to look into it, and if it was not for her I would not be here today with my Sleeve. Another thing is if you are approved for surgery, and there is not a VA close enough to you that performs the procedure they will send you to a civilian surgeon. I was going that route ,but then they decided WV was close enough for me to travel to. I hope this helped you out a little. Good luck, and do not stop fighting for what you want. It will pay out in the end, trust me I know from experience.

[M2G 1,836]

Oh wow, that is really a set-back. I'm so sorry. When I started this process, I was all for the band (even though I couldn't imagine slimeing up my food all the time, but I sort of mentally placed myself into the "that probably won't happen to category.") Our insurance was the first place we had ever even heard of the sleeve. And at my husband's insistance I did more research on the sleeve (this board was a big part of my research) and we both decided that this would be our best option. Now I wouldn't want to go any other way.

That being said, you have to do what is best for you and your finances. You have a lot of soul-searching and a lot of researching ahead of you. I wish you the best of luck!

[Dave_NW 92]

I can see I have some more phone calls to make. :thumbup:

Dave

[Dawn 16]

Good Luck Dave!! I can say this has been very helpful to myself! I was looking into the Band until my Doc said something about the sleeve and now I'm more inline for the sleeve but was worried because we are Tricare Prime (retired) as well but I am having Everything done at an MTF so hopefully they'll say yes!!