Tricare Prime, anyone?

Disney · January 18, 2011

Hey y'all, the bariatric surgeon in my city accepts Tricare Prime. He does the big three, bypass, band and vsg. He knows I'm holding out for VSG and tricare prime to cover it, but he also knows I am saving $ as fast as I can to be a self pay. So,,, whichever comes first. I wish it would be tricare approving, but I am like Tiff, I am NOT holding my breath!

If I do have to self pay, I won't be using him as a surgeon because his price is $4000 more than Dr. Aceves and I am MORE than confindent with using Dr. Aceves so it is a no-brainer. I only worry about any complications afterwards and not being near my surgeon.

Robin Lanzoni · January 18, 2011

Unless the DR is coding it differently, it's not being approved with Standard or Prime.

Here's my challenge: If there's anyone out there that claims their VSG was approved OUTSIDE an MTF with Tricare, please call your Dr and find out what code he used for that approval. That would help alot.

iramback · January 20, 2011

Just visited my surgeon today and they called the TriCare rep with the code today and it is not covered by TriCare Prime at this time and God only knows when they will get around to it. So LapBand here I come...

SugarGrl · January 28, 2011

I have tricare prime and I'm getting it approved. I have a PCM at an Air Force base who has referred me to a civilian surgeon. He says no prob!

I'm at the very beginning of my journey to a possible VSG. My husband is active duty Army and we have Tricare Prime insurance. The Tricare website says that they cover gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery). Would I be correct in assuming that VSG would be the same as vertical banded gastroplasty or gastric stapling??

I have yet to contact my PCM and discuss referral options in my area, so I'm literally at the VERY BEGINNING, but I thought this would be a good place to start asking questions.

Thanks in advance!

Dawn · January 28, 2011

I have tricare prime and I'm getting it approved. I have a PCM at an Air Force base who has referred me to a civilian surgeon. He says no prob!

Is it already approved or did your doctor just say to you it wouldn't be a problem? If it is already approved can you find out what code they used?

Tiffykins · January 28, 2011

I have tricare prime and I'm getting it approved. I have a PCM at an Air Force base who has referred me to a civilian surgeon. He says no prob!

If you can get an ICD-9 code, I would really appreciate it. We have 2 military wives on the board right now fighting to get coverage with civilians so this information would be extremely helpful.

I had 4 surgeons tell me "NO problem", submitted the paperwork, got denials even as a revision patient. Like I said, I've had friends appeal, peer to peer reviews, and file congressional complaints to get coverage for a sleeve with a civilian so if you actually get it, please share how on God's green Earth, this civilian surgeon is working the system to get them approved by Tricare Prime.

me-again · January 29, 2011

PLEASE MAKE IT FAST! BECAUSE SOME OF US ARE ABOUT TO SELF PAY WITHIN THE NEXT 3 MOS. AND THAT INFO COULD SAVE US THOUSANDS!!!

Tiffykins · January 29, 2011

PLEASE MAKE IT FAST! BECAUSE SOME OF US ARE ABOUT TO SELF PAY WITHIN THE NEXT 3 MOS. AND THAT INFO COULD SAVE US THOUSANDS!!!

If you end up self-paying, save every receipt. Even for travel, prescriptions, meals out, supplements, every single receipt because when/if they ever do start covering it, they MIGHT, retroactively reimburse you for it like they did for the band.

I called again today, and it's still NOT a covered a procedure, and I spoke with a claims manager here for Tricare South, and I called Tricare West as well. I confirmed again that all the ICD-9 codes for gastrectomies for weight loss are not covered by Tricare Prime outside of MTFs, and it is NOT a covered procedure with Tricare Standard or Tricare for Life.

me-again · January 29, 2011

THANKS FOR THE INFO TIFFYKINS I WILL REMEMBER TO DO THAT!

SugarGrl · January 29, 2011

I'll probably speak with them next week (they are in another town). The Tech that handels the insurance and put my package together said they do tricare all the time. I asked because I keep hearing on these forums that it would not be approved. They said no prob, they do it all the time. As a matter of fact 3 of my friends have already had it done.

Is it already approved or did your doctor just say to you it wouldn't be a problem? If it is already approved can you find out what code they used?

Dawn · January 30, 2011

I'll probably speak with them next week (they are in another town). The Tech that handels the insurance and put my package together said they do tricare all the time. I asked because I keep hearing on these forums that it would not be approved. They said no prob, they do it all the time. As a matter of fact 3 of my friends have already had it done.

By a civilan doctor in a civilan hosptial? If it's an MTF yeah then it's covered but like Tiffykins just posted she even just called Tricare and it's not a covered procedure! They do cover Bypass and Band though!

Miranda · January 30, 2011

I have medicare and tricare for life cause i am disabled(legally blind) my husband active duty and i go on post and i was also told that is the only place they would cover the vsg. I am in the begining stages but all i need is a support group meeting, psych eval, and the seminar then i will get on the waiting list then it could take any where from a month to a year.

Tiffykins · January 30, 2011

I'll probably speak with them next week (they are in another town). The Tech that handels the insurance and put my package together said they do tricare all the time. I asked because I keep hearing on these forums that it would not be approved. They said no prob, they do it all the time. As a matter of fact 3 of my friends have already had it done.

Is it by a civilian surgeon off post/base?

BZButterfly79 · January 30, 2011

Kassie- Hi! I am excited for you even in the research stage, what the other wives have said is accurate, I've been an Air Force wife for a little over 12 years and at our last duty station where I still had not heard about the sleeve I was looking into the lap band, and THANK GOD did not go through with it but they told me that my primary needed to make a letter to tricare stating I had tried dieting and blah blah and then I would wait for approval and blah blah-point is, the entire thing turned me off. I was so irritated mostly I don't like the third class treatment some physicians have with us because we're just fat wives. I moved and live close enough to a MTF with honestly better docs than I have seen in the civilian sector. Basically I waited, I am still in disbelief that I had a $15,000 procedure but at the same time they probably saved money on all the health problems that were to be. Oh, let me tell you about how I got this thing done from start to finish in less than a month, you can message me if you wanna know.

Char · February 6, 2011

Tricare does pay for VSG..

Are you sure it is the VSG and not vertical banded gastroplasty? Did they actually remove part of your stomach or did they just run a staple line down it? If you did get the VSG approved through a civilian doctor, please get in touch with Tiffany so she can get all the info she can to pursue TriCare's coverage policies. She would be able to use the fact that ANY sleeve gastrectomy has been paid for in her continuing battle with TriCare and possibly force their hand by taking this information back to a Congressional Representative or Senator.