Tricare

[gabby_abby 1]

Has anyone out there used Tricare to pay for VSG?

[Tiffykins 672]

VSG is only covered at military hospitals. Tricare Standard, nor Prime will cover the procedure with a civilian until Medicare picks up VSG fully. They did the same thing with the band years ago.

There are a lot of MTFs performing VSG, you'll just have to call the bariatric department and find out if they offer it.

There is one lady that got Tricare to cover it with Standard, but her story is a bit different and she had to switch to Standard and will remain on Standard through John Hopkins health plan. Her husband is retired so they do not have the normal Tricare Prime, as it's switched to Tricare for Life, and then it's managed through the Medicare system.

I've been round and round with Tricare for over 2.5 years at this point, and had many friends across the U.S. in every Tricare region attempt to get VSG on Standard. One friend even took it to a Congressional complaint level, and she was still denied.

My advice is to first call your MTF, find out if they offer VSG. If they do, get a referral from your PCM, and follow the program set in place by your specific MTF. Every MTF is different, and has different requirements.

If you have questions, please feel free to contact me.

[Texasgrl 2]

I am on Tricare Prime Remote and our policy states that it will be covered. It does not say I have to go to a military hospital, I will have to check further for that but this is my secondary as I have Aetna Primary which covers it to. My first consult appt is tomorrow so will find out more then too.

VSG is only covered at military hospitals. Tricare Standard, nor Prime will cover the procedure with a civilian until Medicare picks up VSG fully. They did the same thing with the band years ago.

There are a lot of MTFs performing VSG, you'll just have to call the bariatric department and find out if they offer it.

There is one lady that got Tricare to cover it with Standard, but her story is a bit different and she had to switch to Standard and will remain on Standard through John Hopkins health plan. Her husband is retired so they do not have the normal Tricare Prime, as it's switched to Tricare for Life, and then it's managed through the Medicare system.

I've been round and round with Tricare for over 2.5 years at this point, and had many friends across the U.S. in every Tricare region attempt to get VSG on Standard. One friend even took it to a Congressional complaint level, and she was still denied.

My advice is to first call your MTF, find out if they offer VSG. If they do, get a referral from your PCM, and follow the program set in place by your specific MTF. Every MTF is different, and has different requirements.

If you have questions, please feel free to contact me.

[Tiffykins 672]

I am on Tricare Prime Remote and our policy states that it will be covered. It does not say I have to go to a military hospital, I will have to check further for that but this is my secondary as I have Aetna Primary which covers it to. My first consult appt is tomorrow so will find out more then too.

That's awesome. Is there an electronic form of your policy that lists sleeve gastrectomy as a covered procedure so I can save it to my archives of Tricare documents? I would love to have this for others that are having issues getting it covered, and I can pass it along to them since so many people are having issues. I can send you my email, or if you could direct me to where is says it on the Tricare website that would be great. I just checked the website for the Tricare regions, for Prime, Standard and Prime Remote and didn't see it listed as a covered procedure under the bariatric procedures. But, I could be missing it.

Hopefully, your Tricare will pick up as secondary and you can get the other portion covered that Aetna might not cover paid for by Tricare. There is a lady on OH that has Tricare as secondary, and she's in the appeal process right now with getting them to cover the other portion that Aetna didn't cover.

[Texasgrl 2]

Sure send me your email, I will scan and send to you. I wish her good luck and hope for myself as well. I have really appreciated your messages and your success with the sleeve and congratulations on your pregnancy. My kids are grown and just got married last year so soon I may be on the YOUNG grandma side too. No rush though because I am a young 45 yr old.

That's awesome. Is there an electronic form of your policy that lists sleeve gastrectomy as a covered procedure so I can save it to my archives of Tricare documents? I would love to have this for others that are having issues getting it covered, and I can pass it along to them since so many people are having issues. I can send you my email, or if you could direct me to where is says it on the Tricare website that would be great. I just checked the website for the Tricare regions, for Prime, Standard and Prime Remote and didn't see it listed as a covered procedure under the bariatric procedures. But, I could be missing it.

Hopefully, your Tricare will pick up as secondary and you can get the other portion covered that Aetna might not cover paid for by Tricare. There is a lady on OH that has Tricare as secondary, and she's in the appeal process right now with getting them to cover the other portion that Aetna didn't cover.

[gabby_abby 1]

My Surgeons Office is going to submit everything today. So I guess I will find out. If not I guess I will have to figure out a back up surgery as self pay in any country is not an option. RNY seems so dramatic and risky and the lap bad is just well there is something inside of me FOREVER, which may have to be taken out. grrrr...

[gabby_abby 1]

now I can not even get the tricare.mil site to come up so see what they say about it. I will be so disapointed.... Double Grrrrrr

[lyn 5]

Great news Tricare does cover your sleeve, they don't cover the band because they insist it be done in an overnight facility and most lapbands do not require that. That being said I had my sleeve done at a miltary facility and it was fabulous. At my support meeting last month they brought in a local hospital to talk to us about their bariatric center and the fact that they were going to take a few of the patients scheduled for surgery at our local military hospital because they are in the midst of a move to the larger hospital here in town over the summer. So it is possible. I wish you the best, please call tricare and check it out, I think you will be pleasantly surprised.

[gabby_abby 1]

Here is what i found on line.

https://www.hnfs.net/content/hnfs/home/tn/common/benefits_a_to_z/gastric_bypass/gastric_bypass.html/pp/content/hnfs/home/tn/bene.html

Gastric bypass, gastric stapling, gastroplasty, vertical banded gastroplasty and laparoscopic adjustable gastric banding are covered benefits when the following conditions are met:

• The patient is 100 pounds over the ideal weight for height and bone structure (per the most current Metropolitan Life Table) 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; or
• The patient is 200 percent or more of the ideal weight for height and bone structure (per the most current Metropolitan Life Table), regardless of associated medical conditions; and
• InterQual^® criteria, which is used during the authorization process, confirms the requested surgery is appropriate and medically necessary. (InterQual^® is a widely used product of McKesson Corporation that provides evidence-based clinical decision support for health plans, hospitals, government payers and various other organizations.)

A pre-operative psychological evaluation and psychological testing, six hours or less, are covered benefits as part of the initial assessment to determine if the individual meets the requirements for surgery. This psychological evaluation as part of the psychological testing does not count towards the initial eight (8) outpatient behavioral health visits.

Cost Information

Prior Authorization Requirements

• TRICARE Prime beneficiaries require prior authorization for all weight loss procedures.
• For TRICARE Standard beneficiaries, we recommend providers submit a TRICARE Service Request form to determine if TRICARE requirements are met.

Services Not Covered

• Office visits solely for the treatment of obesity
• Non-surgical procedures for treatment of obesity
• Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633)
• Gastric bubble or balloon
• Sleeve gastrectomy (CPT 43775)
• Gastric wrapping/open gastric banding (CPT code 43843)
• Unlisted procedures (CPT codes 43659, 43999 and 49329)

(This list is not all inclusive.)

[lyn 5]

Are you in Texas?

[gabby_abby 1]

Nope I am in Illinois. There is no major military hospital here anymore, we get farmed out.

Are you in Texas?

[lyn 5]

There has to be something that can be done, like I said here in Texas they are doing them locally as well at the military facility. I would call tricare and speak with someone directly. I called tricare at the start of my journey to ask about lapbanding and that is how I found out about the facility here in town that did all three procedures. They told me the reason that they don't approve for the outside facilities was because of the overnight stays. Perhaps if you call them directly you can find out what parameters they need in order to approve. Maybe then you can find a Dr that meets all those requirements and move forward. They were very helpful at Tricare, If you don't get someone helpful the first time hang up and call again. Let me know how you make out with them.

[Tiffykins 672]

Here is what i found on line.

https://www.hnfs.net...me/tn/bene.html

Gastric bypass, gastric stapling, gastroplasty, vertical banded gastroplasty and laparoscopic adjustable gastric banding are covered benefits when the following conditions are met:

• The patient is 100 pounds over the ideal weight for height and bone structure (per the most current Metropolitan Life Table) 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; or
• The patient is 200 percent or more of the ideal weight for height and bone structure (per the most current Metropolitan Life Table), regardless of associated medical conditions; and
• InterQual^® criteria, which is used during the authorization process, confirms the requested surgery is appropriate and medically necessary. (InterQual^® is a widely used product of McKesson Corporation that provides evidence-based clinical decision support for health plans, hospitals, government payers and various other organizations.)

A pre-operative psychological evaluation and psychological testing, six hours or less, are covered benefits as part of the initial assessment to determine if the individual meets the requirements for surgery. This psychological evaluation as part of the psychological testing does not count towards the initial eight (8) outpatient behavioral health visits.

Cost Information

Prior Authorization Requirements

• TRICARE Prime beneficiaries require prior authorization for all weight loss procedures.
• For TRICARE Standard beneficiaries, we recommend providers submit a TRICARE Service Request form to determine if TRICARE requirements are met.

Services Not Covered

• Office visits solely for the treatment of obesity
• Non-surgical procedures for treatment of obesity
• Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) (CPT codes 43645, 43845, 43847 or 43633)
• Gastric bubble or balloon
• Sleeve gastrectomy (CPT 43775)
• Gastric wrapping/open gastric banding (CPT code 43843)
• Unlisted procedures (CPT codes 43659, 43999 and 49329)

(This list is not all inclusive.)

That's all the same information I've been given.

It is NOT covered because Medicare is NOT covering it, and Tricare is a gov't ran insurance that follows suit on Medicare covering things.

They did the same exact thing with lapbands several years ago, and then they went back and retroactively paid for people that self-paid for the band.