Port Revision with Tricare

AZnikki · August 24, 2008

Has anyone had to get a port revision through Tricare? If so, please contact me. I'm having some trouble with approval and I've got a leak in my port!:biggrin:

Busy296 · August 24, 2008

I haven't. I was wondering also, I need a smaller one. Seems I lost weight and there is a smaller port available. Mine seems to be tender sometimes. I need the answer...

clayverde · August 24, 2008

I wish I had more answers for you, but I thought I would post the little bit of info I could. I recently had an issue because Tricare didn't cover a nutrition appointment and then the hospital passes the bill along to me. I called Tricare with a WTF, who told me I had to appeal it and convince them it should be a covered service, etc. After more research and a close reading of my Explanation of Benefits, it clearly stated that I was not responsible for those charges. Now I am in the middle of back and forth between Tricare and the hospital, but Tricare is now very supportive. When I called Tricare the second time and told them that the first woman told me it just wasn't covered and I would have to pay it or appeal and asked why she didn't know what was really going on - the lady at Tricare told me that part of the problem right now is that the Lapband was recently added as a covered service. The Lapband laproscopic surgery is REALLY a new addition to covered services. She said that because of that, they are definitely having growing pains of what is necessary, what should be covered, what price is allowed, blah blah. She said that if I had really had to appeal, that I wouldn't be alone because it is happening a lot right now. They haven't really gotten all the kinks out. SO, I'm just letting you know that this is not a standard thing yet. I can tell from the boards that it is still pretty crazy - some people got approved no problem, others were denied and have to appeal, some are told a, b, and c are the only allowed co-morbidities while others are told a through g. So please keep that in mind when going through this. AND don't give up! The lack of standards right now may work in your favor because normally they just say, oh this procedure, not covered, done. And you can't convince them to just change their minds. But here, it isn't that set yet which means you really might be able to show them in an appeal why the procedure is necessary, how it impacts the surgery, the results, whatever.

Good Luck!!! :biggrin:

AZnikki · August 27, 2008

Thanks so much for the advice/information/support...so guess what all?!?! I got it approved...here's what happened:

The first CPT code that they used got denied--it was 43886 (revise gastric port, open)...then, I called Tricare and asked about a bunch of CPT codes that I found on google and one of them was on their list of approvals...they said it has to be proved medically necessary and have prior approval...but...today, I got the approval!!! I'm not sure what it means yet, but the CPT code that I suggested to the dr's office was 43771 (lap,revise adjust gastric band)--the lap indicates laproscopic. So, anyway the reason I don't know what it means is because one of them says approved and then another one with the same CPT code says approved with modification...I'm not sure if that is because my doctor will be doing it outpatient or what?!? Regardless, I will be calling surgeon tomorrow and will hopefully have surgery on Friday!!! Woo HOO!!!! For those of you trying to get approval through Tricare (maybe even other insurances) TRY THIS WAY...the CPT codes are universal--it's just up to each insurance company as to what/how they cover it. Anyway--I'll post again once I talk to the doctor tomorrow!

aculberg · August 27, 2008

Question for you guys, Does Tricare cover fills? I am approved for the surgery, but cant find anywhere that says they actually cover fills?! Thanks!!

Long2BFree · August 28, 2008

Question for you guys, Does Tricare cover fills? I am approved for the surgery, but cant find anywhere that says they actually cover fills?! Thanks!!

Tricare told me that fills are covered 100% but I would just call to make sure they haven't changed anything.

clayverde · August 29, 2008

Tricare definitely covers the fills 100% (at least for Tricare Prime - I don't know about Standard). The only thing to be aware of is the normal issue of network and non-network providers. But if you use a Tricare approved Dr., then the fills are covered completely. Anyone know if there is a limit to them though? I haven't heard of any, but it just occurred to me know to wonder if Tricare will only cover 1 fill every 3 months for instance or something like that. Just curious... I don't think so and I not only really researched Tricare and their coverage, but I had a great Tricare representative who has contacted me at regular intervals since the approval process to check on if i was ready for the surgery, if I felt I was educated enough about the whole process, if I had any questions on my benefits, how am I finding the post-op recovery time, am I happy with my surgeon, etc. So, because of that, I have found my experience to be a lot smoother than other Tricare beneficiaries who have had to do so much legwork on their own.

Long2BFree · August 29, 2008

Tricare definitely covers the fills 100% (at least for Tricare Prime - I don't know about Standard). The only thing to be aware of is the normal issue of network and non-network providers. But if you use a Tricare approved Dr., then the fills are covered completely. Anyone know if there is a limit to them though? I haven't heard of any, but it just occurred to me know to wonder if Tricare will only cover 1 fill every 3 months for instance or something like that. Just curious... I don't think so and I not only really researched Tricare and their coverage, but I had a great Tricare representative who has contacted me at regular intervals since the approval process to check on if i was ready for the surgery, if I felt I was educated enough about the whole process, if I had any questions on my benefits, how am I finding the post-op recovery time, am I happy with my surgeon, etc. So, because of that, I have found my experience to be a lot smoother than other Tricare beneficiaries who have had to do so much legwork on their own.

I'm Tricare Standard and they told me I'm covered 100% for fills. I just had my first one a couple of days ago and haven't received the EOB but I'm taking them at their word.