Tricare Prime, anyone?

[lhitt3813 1]

HELLO!

my husband is active duty army and tricare did allow me several referrals to civilian doctors for the vsg surgery. i lived in washington dc at the time and they were trying to phase out the program at walter reed (since they are closing it down) and they were building a new hospital on fort belvoir that would include a new bariatric center so that only left bethesda for the whole area and they were on a 8 month to a year wait list to get into the seminar and into the program. it was a pain! i went through 6 referrals to civilians and didn't find one surgeon that i liked. i started to get very discouraged. well i called bethesda and spoke with the bariatric coordinator and discovered that due to the long wait list and the amount of pcs moves that familys in the military make the wait list was much shorter. so i got into the seminar and met the surgeon at bethesda and loved him. he was so personable and kind. the dc area is very different than other areas for weight loss surgery. it took me a year to get all my appointments done and have surgery. i almost didnt get my surgery due to a pcs move. we moved in june and my surgery was in august. i convinced my doc that i would be able to stay in dc until he cleared me to go home to az and after many long talks and emails we made it work. i am now 5.5 months post op and i have lost 85 pounds since surgery and 35 pre op. i still have another 40 or so to go but i will say that this is a fight that i am glad i didnt give up on!

best of luck to you!

[Tiffykins 672]

HELLO!

my husband is active duty army and tricare did allow me several referrals to civilian doctors for the vsg surgery. i lived in washington dc at the time and they were trying to phase out the program at walter reed (since they are closing it down) and they were building a new hospital on fort belvoir that would include a new bariatric center so that only left bethesda for the whole area and they were on a 8 month to a year wait list to get into the seminar and into the program. it was a pain! i went through 6 referrals to civilians and didn't find one surgeon that i liked. i started to get very discouraged. well i called bethesda and spoke with the bariatric coordinator and discovered that due to the long wait list and the amount of pcs moves that familys in the military make the wait list was much shorter. so i got into the seminar and met the surgeon at bethesda and loved him. he was so personable and kind. the dc area is very different than other areas for weight loss surgery. it took me a year to get all my appointments done and have surgery. i almost didnt get my surgery due to a pcs move. we moved in june and my surgery was in august. i convinced my doc that i would be able to stay in dc until he cleared me to go home to az and after many long talks and emails we made it work. i am now 5.5 months post op and i have lost 85 pounds since surgery and 35 pre op. i still have another 40 or so to go but i will say that this is a fight that i am glad i didnt give up on!

best of luck to you!

I'm so glad you got your sleeve. I've friends get sent to civilian surgeons as well, go through all the hoops and end up with denial letters even after pre-authorization letters were given. Funny thing is that you aren't the only one dealing with Walter Reed/Bethesda nightmare up there. I have 2 friend going through the same battle right now.

Thanks for sharing your information and experience ! ! ! Best wishes on your continued success.

[MiCollins 0]

Can you share how you got it covered with a civilian???? If you read my post correctly I specifically state that it is indeed covered at MTFs, but not with civilians.

Because every document, every rep, every customer advocate, every other surgeon and insurance coordinator I've talked to in 4 different states, Tri-West, Tricare south (Humana, and the region I'm in), and Tricare north all deny with a civilian.

So, since I'm wrong, and you've had it covered with a civilian, please share how you managed to get it covered with Prime with a civilian surgeon.

I'd like to get further information, how you out of the 100s of others that I've spoken with that have been denied, had a Congressional compliant denied, yet you were approved with a civilian surgeon.

Not sure if you didn't read my reply thoroughly, or but, you might want to reread what I posted.

I see a civilian PCM, and all my referrals get kicked to civilians so I honestly went through the wringer just to get a referral to on base provider because our system works a little different when we see civilians on base. We get to see off base providers because we are at a small base with tons of retirees, and appointments are very difficult to get in a timely manner. Plus, we do not live on base (9miles from the front gate), but we still get to see civis for everything.

I had my revision performed at a MTF and it was covered 100%.

Hi,

I've posted this in a couple of spots, because I ran across it when I was on a Google Search for Gastric Sleeve Surgery Tricare

There's a new ruling as of today for surgery for the morbidly obese. It states that if it is nationally accepted and medically necessary, it will be covered by tricare. Here's the link to the Federal Register Document on the Department of Defense Final Ruling. I think this could mean the sleeve will be covered as of march, but read it and see. There's a contact person and phone number in the document, so that might help with insurance issues.

Here's the Link.

My link

DEPARTMENt oF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD–2008–HA–0057]

RIN 0720–AB24

TRICARE Program; Surgery for Morbid

Obesity

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

SUMMARY: This final rule adds a

definition of Bariatric Surgery, amends

the definition of Morbid Obesity, and

revises the language relating to the

treatment of morbid obesity to allow

benefit consideration for newer bariatric

surgical procedures that are considered

appropriate medical care. The final rule

removes language that specifically

limits the types of surgical procedures

to treat co-morbid conditions associated

with morbid obesity and retains the

TRICARE Program exclusion of nonsurgical

interventions related to morbid

obesity, obesity and/or weight

reduction. This final rule is necessary to

allow coverage for other surgical

procedures that reduce or resolve comorbid

conditions associated with

morbid obesity and the use of the Body

Mass Index (BMI), which is the more

accurate measure for excess weight to

estimate relative risk of disease. As new

technologies or procedures evolve from

investigational into generally accepted

norms for medical practice, the statutes

and regulations governing the TRICARE

Program allow the Department to offer

beneficiaries these new benefits. These

changes are required in order to allow

the Department to provide these newer

technologies and procedures for the

treatment of morbid obesity as they

evolve.

DATES: Effective Date: This rule is

effective March 16, 2011.

ADDRESSES: TRICARE Management

Activity, Medical Benefits and

Reimbursement Branch, 16401 East

Centretech Parkway, Aurora, CO 80011–

9066.

FOR FURTHER INFORMATION CONTACT: Gail

L. Jones, Medical Benefits and

Reimbursement Branch, TRICARE

Management Activity, telephone (303)

676–3401.

VerDate Mar<15>2010 14:08 Feb 11, 2011 Jkt 223001 PO 00000 Frm 00030 Fmt 4700 Sfmt 4700 E:\FR\FM\14FER1.SGM 14FER1 WReier-Aviles on DSKGBLS3C1PROD with RULES

Federal Register /Vol. 76, No. 30 /Monday, February 14, 2011 /Rules and Regulations 8295

SUPPLEMENTARY INFORMATION:

I. Background

On December 27, 1982, the

Department of Defense (DoD) published

a final rule in the Federal Register (47

FR 57491–57493) that restricted surgical

intervention for morbid obesity to

gastric bypass, gastric stapling, or

gastroplasty method (excluding all other

types) when the primary purpose of

surgery is to treat a severe related

medical illness or medical condition.

The severe medical conditions or illness

associated with morbid obesity included

diabetes mellitus, hypertension,

cholecystitis, narcolepsy, Pickwickian

Syndrome (and other severe respiratory

disease), hypothalamic disorders, and

severe arthritis of the weight-bearing

joints. The DoD also limited program

payments to two categories of patients:

(1) Those who weighed 100 pounds over

their ideal weight with a specific severe

medical condition; and (2) those who

were 200 percent or more over their

ideal weight with no medical

complications required. Program

payment was made available as well in

cases in which a patient, who originally

met the criteria, received an intestinal

bypass, or other surgery for obesity and,

because of complications, required a

second surgery. Payment was allowed

even though the patient’s condition may

not have technically met the definition

of morbid obesity because of the weight

that was already lost following the

initial surgery. All other surgeries

including non-surgical treatment related

to morbid obesity, obesity, and/or

weight reduction were excluded.

The DoD used the definition of

morbid obesity, which was based on the

Metropolitan Life Table and used then

by other major health care plans, as well

as reflected the 1982 general opinion

regarding which cases justify surgical

intervention. The DoD decided, at the

time, that it was necessary to be very

specific in benefit parameters due to

fiscal responsibility and to ensure that

Program beneficiaries were not being

exposed to less than fully developed

medical technology or procedures.

At the time the current regulation was

written in 1982, gastric bypass, gastric

stapling, and gastroplasty methods were

the recognized surgeries for morbid

obesity. However, in recent years, other

bariatric surgical procedures have

evolved and some have a substantial

body of literature to support their safety

and efficacy. Unlike the original rule

that listed the specific surgical

procedures and the clinical conditions

for which coverage may be extended;

this final rule authorizes benefit

consideration for those bariatric surgical

procedures that have moved from the

unproven status to the position of

nationally accepted medical practice, as

determined by the Program standard of

reliable evidence.

Also in 1982 during development of

the current regulation for morbid

obesity, overweight and obesity were

typically measured with height-weight

tables (such as the Metropolitan Life

Table). The 1982 regulation restricted

eligibility for bariatric surgery to

individuals who exceed their ideal

weight for height by 100 pounds with an

associated severe medical condition, or

200 percent or more over their ideal

body weight with no associated medical

condition required.

This final rule changes the Program

definition of morbid obesity to reflect

the current nationally accepted medical

use of the BMI, rather than the typical

assessed height-weight table (i.e., the

Metropolitan Life Table), to determine

an individual’s eligibility for bariatric

surgical treatment. The BMI is the more

accurate measure for excess weight to

estimate relative risk of disease. Since

there now are more than 30 major

diseases associated with obesity, the

final rule requires the Director, TMA, to

issue specific criteria for co-morbid

conditions exacerbated or caused by

(morbid) obesity, as determined by the

Program standard of reliable evidence.

This final rule does not expand the

TRICARE benefit for morbid obesity

surgery. However, it does make the

specific procedures that are covered, as

well as the clinical conditions for which

coverage may be extended, a matter of

policy. In other words, new bariatric

surgery procedures may be added to the

TRICARE benefit structure as such

procedures are proven safe and effective

and are established as nationally

accepted medical practice as

determined by the Program standard of

reliable evidence.

[Dawn 16]

Well I really hope this is the news those have been waiting for!! Keeping my fingers crossed!

[seniorsleever 17]

I also went to this site referenced above and read all the fine print. I noticed that under the section marked "Public Comments," this comment and rebuttal was printed:

"Comment: Another commenter agrees with the changes as well but recommends that the list of obesity-associated co-morbidities be a complete, inclusive list to prevent inappropriate denial of service. The commenter goes on to state that covered procedures should include the laparoscopic vertical sleeve gastrectomy and duodenal switch procedures.Show citation box

Response: We appreciate the suggestion that morbid obesity multiple co-morbidities be a complete, inclusive list and will consider it as one of many recommendations in revising the benefit policy. We disagree with the commenter's suggestion that vertical sleeve gastrectomy (VSG) and biliopancreatic diversion with duodenal switch (BPD/DS) should be covered under the TRICARE Program. The evidence evaluating the safety and efficacy of BPD/DS and VSG do not meet the program specific standards of reliable evidence. Existing data does suggest the use of these procedures is a possible benefit to some patients but there is incomplete information to predict the effect of long-term outcomes. This lack of information relating to the long-term outcomes is a matter of concern to the Department. Medical literature indicates as well that well-controlled trials are needed to determine both short-term and long-term safety and efficacy of BPD/DS and long-term (> 5 years) weight loss and co-morbidity resolution data for VSG. The Agency will continue to monitor the development of the literature and the status of ongoing well-controlled clinical trials regarding the effectiveness of the laparoscopic VSG and BPD/DS procedures. At such time when the reliable evidence demonstrates that these bariatric surgical procedures have proven medical effectiveness, the Director, TMA will initiate action to cover these procedures."

I have placed a call to Ms. Gail Jones, who is the contact person for this information. She was not in, but I left a message for her to call me back. When I get anything definitive regarding the possible coverage of VSG, I will post it here.

[Tiffykins 672]

I also went to this site referenced above and read all the fine print. I noticed that under the section marked "Public Comments," this comment and rebuttal was printed:

"Comment: Another commenter agrees with the changes as well but recommends that the list of obesity-associated co-morbidities be a complete, inclusive list to prevent inappropriate denial of service. The commenter goes on to state that covered procedures should include the laparoscopic vertical sleeve gastrectomy and duodenal switch procedures.Show citation box

Response: We appreciate the suggestion that morbid obesity multiple co-morbidities be a complete, inclusive list and will consider it as one of many recommendations in revising the benefit policy. We disagree with the commenter's suggestion that vertical sleeve gastrectomy (VSG) and biliopancreatic diversion with duodenal switch (BPD/DS) should be covered under the TRICARE Program. The evidence evaluating the safety and efficacy of BPD/DS and VSG do not meet the program specific standards of reliable evidence. Existing data does suggest the use of these procedures is a possible benefit to some patients but there is incomplete information to predict the effect of long-term outcomes. This lack of information relating to the long-term outcomes is a matter of concern to the Department. Medical literature indicates as well that well-controlled trials are needed to determine both short-term and long-term safety and efficacy of BPD/DS and long-term (> 5 years) weight loss and co-morbidity resolution data for VSG. The Agency will continue to monitor the development of the literature and the status of ongoing well-controlled clinical trials regarding the effectiveness of the laparoscopic VSG and BPD/DS procedures. At such time when the reliable evidence demonstrates that these bariatric surgical procedures have proven medical effectiveness, the Director, TMA will initiate action to cover these procedures."

I have placed a call to Ms. Gail Jones, who is the contact person for this information. She was not in, but I left a message for her to call me back. When I get anything definitive regarding the possible coverage of VSG, I will post it here.

That's pretty much the same statement that Medicare is giving so they are still following suit behind Medicare. It's just not going to happen yet. I know I sound like a negative nelly, but they are not gonna do it anytime soon from everything I've read and been told.

I hope this does help get congressional complaints approved because that's going to be the only way that it's gonna happen with a civilian.

Fingers crossed something changes soon. When I called last week, spoke with a case manager, and a patient advocate, I was given the same song and dance that it would be October (the military fiscal year begins) for them to consider it. But, who knows anymore ! ! !

[Shae 44]

Can you please share the name and location of your MTF? I am in Biloxi, MS and as far as I am aware, Keesler AFB's 81st Medical Group at Keesler Medical Center no longer has a Bariatric department due to cutbacks.

Thanks in advance

Shae

I've had 5 friends now go through the process here at our MTF, and it takes about 6-8 weeks to get all the appointments scheduled and completed. A surgery date has always happened within 2 months here so not big wait compared to others.

It depends on how many surgeons they have available to perform the sleeve. We had 2, then went down to 1, then back up to 2 so it kind of depends on each specific location and how back logged they are on bariatrics.

Here is a MTF locator link for you to try, that way you don't have to try to hunt down numbers.

http://www.tricare.mil/MTF/

[Tiffykins 672]

Can you please share the name and location of your MTF? I am in Biloxi, MS and as far as I am aware, Keesler AFB's 81st Medical Group at Keesler Medical Center no longer has a Bariatric department due to cutbacks.

Thanks in advance

Shae

Eglin AFB, Florida

I just had my 2 year follow up appointment yesterday, and my surgeon has received orders to MacDill. If you want the sleeve, the only surgeon that I know that has experience with VSG, and the only other surgeon I trust, and know because he took over my care while my primary surgeon deployed, is Dr. Riley. Both are fabulous, and very experienced. Dr. Riley is only on for another year at this point. If you need help getting a referral put in, or any further information, please let me know.

[Shae 44]

I would love to know what I need to do!! I have been trying to find a way to have the sleeve since I heard about it 4 years ago. I see a civilian PCM who is on board with me getting the procedure. How do I give you my contact information without posting it here?

Eglin AFB, Florida

I just had my 2 year follow up appointment yesterday, and my surgeon has received orders to MacDill. If you want the sleeve, the only surgeon that I know that has experience with VSG, and the only other surgeon I trust, and know because he took over my care while my primary surgeon deployed, is Dr. Riley. Both are fabulous, and very experienced. Dr. Riley is only on for another year at this point. If you need help getting a referral put in, or any further information, please let me know.

[Tiffykins 672]

I would love to know what I need to do!! I have been trying to find a way to have the sleeve since I heard about it 4 years ago. I see a civilian PCM who is on board with me getting the procedure. How do I give you my contact information without posting it here?

If you have Facebook, you can add me over there facebook.com/sparkleandcharm

I'll shoot you a private message that you can reply to with your questions.

Are you on Tricare Prime or Standard?

[gingersnap 11]

This looks promising! Medicare is now in the consideration process for coverage of the LSG and as I understand Tricare follows Medicare. So we maybe looking at approval sometime next summer.

https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?&&fromdb=true&NCAId=258

http://www.internalmedicinenews.com/news/gastroenterology/single-article/cms-considers-coverage-of-laparoscopic-sleeve-gastrectomy/fc3fe54035.html

[Lizbeth 16]

Ok people if I have a civilian doc and have to get reffered to a mtf for the surgery 4hrs away does the refferal go to the mtf or tricare?

[gingersnap 11]

Regarding Tricare Travel Reimbursement for 100 miles plus. Will they cover travel for VSG? Any tips on what I should or should not say to my on base benefits guy before I say too much? I'm going to be traveling 150 miles to Forth Gordon and any reimbursement would be helpful!

I've printed the policy and it looks like they should cover it, but in my mind if they don't cover the VSG they won't cover the travel to get it. Please tell me your experience!

[Aloadoff 0]

This is the most recent 2012 Sleeve Gastrectomy information from TRICARE:

http://www.humana-military.com/library/pdf/ps-bull-i1-2012.pdf

It says it does cover the surgery and has conditions on what your BMI needs to be to cover the surgery.

Hope this helps everyone.

[Aloadoff 0]

Just wanted to also point out that currently the Sleeve is not covered.

According to this link: http://www.humana-mi...ull-i1-2012.pdf

The Vertical Band Gastrectomy is covered.... but the Vertical Sleeve Gastrectomy which is a different type of surgery IS NOT covered .

Haven't seen any updated info for 2012 except for this. Hope this helps as well.

ALoadOff