TRICARE Now Covers “Lap-Band” Surgery

January 16, 2008 No. 08-04

FALLS CHURCH, VA. – TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007.

“We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community,” said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. “We’ve added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health.”

Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person’s height and bone structure may also indicate morbid obesity.

In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.

Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online at http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManuals.DisplayManualSeriesInfo&ManualSeries=POLICY&TP02=67#TP02. A search for "morbid obesity" goes directly to the correct section.

About TRICARE Management Activity and the Military Health System

TRICARE Management Activity, the Defense Department activity that administers the health care plan for the uniformed services, retirees and their families, serves more than 9.1 million eligible beneficiaries worldwide in the Military Health System (MHS). The mission of the MHS is to enhance the Department of Defense and national security by providing health support for the full range of military operations. The MHS provides quality medical care through a network of providers, military treatment facilities, medical clinics and dental clinics worldwide.

Don't be afraid to swith PCM's if they don't help you. Some doctors are nice about it, others are a pain. My first doctor told me some horror stories to try to make me change my mind about lapband. So, I changed doctors and had no problem after that. Don't be afraid to tell them what you want, it's not their body, it's yours.

Good Luck!! Michelle

Hey there again,

I wanted to tell you that when I visited my PCM, I had already researched a surgeon and told my PCM who I wanted to be referred to and why. If you show them you are serious and informed they are more opt to listen. My PCM even told me she was impressed by my research.

Michelle

Hi Everyone,

I had the lapband in June of 07 with another insurance so I'm hoping I can drop the new insurance and have coverage with Tricare again and they will cover the Fills! This is Great News!!!!

Here is an articel that was in the Air Force Times Today:

Tricare now covers lap-band surgery - Air Force News, opinions, editorials, news from Iraq, photos, reports - Air Force Times

Tricare now covers lap-band surgery

By Karen Jowers - Staff writer

Posted : Wednesday Jan 23, 2008 13:13:50 EST

Seriously overweight Tricare patients have a new surgical option available to them: Tricare now pays for what is commonly known as “lap-band” surgery, in which surgeons place a hollow band around the stomach at its upper end, limiting the amount of food that can be eaten.

Although the Tricare policy change was announced just recently, the coverage is retroactive to Feb. 1, 2007. Patients who received the surgery since then can submit a claim for reimbursement, a Tricare spokesman said.

Tricare officials stress that laparoscopic adjustable gastric banding surgery is only for morbidly obese patients — those more than 100 pounds over the ideal weight for their height and bone structure, and whose weight is associated with severe medical conditions known to have higher mortality rates.

Tricare will also cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and requires a second surgery because of complications.

“We at Tricare are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community,” said Army Maj. Gen. Elder Granger, deputy director of the Tricare Management Activity, in an announcement of the policy change. “We’ve added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health.”

The band, which can be tightened or loosened over time, creates a small pouch and narrow passage into the larger remaining part of the stomach. The procedure is reversible and does not require the stomach to be cut, stapled or opened, so there is less risk of infection, although there are possible side effects.

Hi Everyone,

I had the lapband in June of 07 with another insurance so I'm hoping I can drop the new insurance and have coverage with Tricare again and they will cover the Fills! This is Great News!!!!

Here is an articel that was in the Air Force Times Today:

Tricare now covers lap-band surgery - Air Force News, opinions, editorials, news from Iraq, photos, reports - Air Force Times

Tricare now covers lap-band surgery

By Karen Jowers - Staff writer

Posted : Wednesday Jan 23, 2008 13:13:50 EST

Seriously overweight Tricare patients have a new surgical option available to them: Tricare now pays for what is commonly known as “lap-band” surgery, in which surgeons place a hollow band around the stomach at its upper end, limiting the amount of food that can be eaten.

Although the Tricare policy change was announced just recently, the coverage is retroactive to Feb. 1, 2007. Patients who received the surgery since then can submit a claim for reimbursement, a Tricare spokesman said.

Tricare officials stress that laparoscopic adjustable gastric banding surgery is only for morbidly obese patients — those more than 100 pounds over the ideal weight for their height and bone structure, and whose weight is associated with severe medical conditions known to have higher mortality rates.

Tricare will also cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and requires a second surgery because of complications.

“We at Tricare are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community,” said Army Maj. Gen. Elder Granger, deputy director of the Tricare Management Activity, in an announcement of the policy change. “We’ve added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health.”

The band, which can be tightened or loosened over time, creates a small pouch and narrow passage into the larger remaining part of the stomach. The procedure is reversible and does not require the stomach to be cut, stapled or opened, so there is less risk of infection, although there are possible side effects.

I just wanted to add to this most excellent post that this article was posted in all the major electronic military newspapers (probably a portal post). Here are the links:

Air Force Times: http://www.airforcetimes.com/news/2008/01/military_lapband_tricare_080123w/

Army Times: http://www.armytimes.com/news/2008/01/military_lapband_tricare_080123w/

Navy Times: http://www.navytimes.com/news/2008/01/military_lapband_tricare_080123w/

Hi, I'm new to the board. I just found out that tri-care approves this now and am so excited. I immediately called and verified it and then called a lap band doctor who then called and verified it. I have my 1st appointment on 1/30 for a consultation. I just have to get a referral from my PCM before I can go. I'm very worried that I won't weigh enough though. I am 5'6", 222 with a BMI of 35. But I do have some other medical documented problems and documented weight loss attempts to help with approval.

Am I getting my hopes up by thinking that I meet the criteria and that's why the doctor is seeing me or is it normal for them to see you for the initial consultation? His staff is aware of my size so I would hope they would screen me out and wouldn't let me have the consultation if I didn't meet the criteria.

Thanks for any info anyone can give me.

Amy

Lapband will be officially updated January 25, 2008

I was told by Humana Tricare that all systems should be updated today in the system for the lap-band procedure, so you should not hear from a Tricare rep that they do not see where its covered. I already had my visits authorized to see my doctor before today, approx. a week ago. You must be 100lbs overweight with comorbidities according to the metropolitan life chart. If you fall 100lbs overweight on the chart you're good. If you should weigh 135lbs and you weight 270 or more, you automatically qualify, that is what 200% means, basically you must be double your weight. BMI has no bearing with tricare only weight and height for you bone structure. Weight and bone structure is based on the Metropolitan life charts. You will eventually need clearances from various specialty doctors and your PCM, nutrition eval, and pschy eval, after your packet is accepted by your bariatric doctor.

Last edited by trell : Today at 09:48 AM.

Hi, Randi, How much do to the fills cost? If tricare covers fills, they should also cover the fills you have paid for as well. Retroactive for insurance companies means that it will go back and cover what you should not have had to pay from the start. From working in the insurance field, they may cover only what you have paid up until now or up until December. They may request that you go to a MTF, starting now. The question is now, do they cover the fills? I have not found that out yet, but will call next week, I want to make sure everything is updated first, they sound like they can not look up anything unless the computer tells them.

Thanks so much for the info. I wonder if they go by the bottom number of the "ideal" weight scale or the high number!! The high number would be good!! The docs office told me that they had never been denied by tricare before. But the lap band is a new thing for tricare, so we'll see. I'll keep you posted! thanks again

Hi, Randi, How much do to the fills cost? If tricare covers fills, they should also cover the fills you have paid for as well. Retroactive for insurance companies means that it will go back and cover what you should not have had to pay from the start. From working in the insurance field, they may cover only what you have paid up until now or up until December. They may request that you go to a MTF, starting now. The question is now, do they cover the fills? I have not found that out yet, but will call next week, I want to make sure everything is updated first, they sound like they can not look up anything unless the computer tells them.

Trell,

Tricare covers fills. The code for that procedure is HCPCS S2083 or CPT 90772. Since Tricare covers fills and your surgeon accepts Tricare (some don't), then your portion would be the co-pay.

All my fills are done under fluoroscope at a cost of $70 for a fill/unfill, but I'm not sure of the CPT Code for that because it's a type of x-ray. However, fluoroscope fills is one of the criteria I used to select my surgeon. I didn't want to run the risk of a re-operation to replace punctured tubing or multiple needle sticks to access my low-profile port from the surgeon or the physician assistant doing "blind" fills. Fills under fluoroscope has made for a perfect "bulls-eye" everytime when accessing my port.

I'm not grandfathered by the new Tricare Policy on banding. So, I've already had my PCM to submit a referral to try and get follow-up visits to include fills covered to reduce my portion of the payment to the co-pay. However, I live near two major MTFs -- Wilford Hall Medical Center and Brookes Army Medical Center. If either can provide follow-up treatment for the lap-band, it's likely Tricare may not pay for it.

Hi, I'm new to the board. I just found out that tri-care approves this now and am so excited. I immediately called and verified it and then called a lap band doctor who then called and verified it. I have my 1st appointment on 1/30 for a consultation. I just have to get a referral from my PCM before I can go. I'm very worried that I won't weigh enough though. I am 5'6", 222 with a BMI of 35. But I do have some other medical documented problems and documented weight loss attempts to help with approval.

Am I getting my hopes up by thinking that I meet the criteria and that's why the doctor is seeing me or is it normal for them to see you for the initial consultation? His staff is aware of my size so I would hope they would screen me out and wouldn't let me have the consultation if I didn't meet the criteria.

Thanks for any info anyone can give me.

Amy

Hi, Amy,

Tricare uses the Metroplitan Life Insurance Tables NOT BMI to determine whether you will be approved for surgery. I'm going to post links to the current Tricare Policy and a Metlife Table below for your reference. However, let your PCM/Surgeon be the one to determine whether you qualify:

Current Tricare Policy: http://www.lapbandtalk.com/f8/tricare-now-covers-lap-band-surgery-49990/#post696335

Metlife Table: MetLife Height-Weight Tables

Thank you Randi for the info. I guess I'll have to wait until Wednesday to find out what the surgeon says!!