Appeal Tricare Prime C200odes 15830, 15832-50,15835

Hello all,
I had WLS 2007 and lost a total of 125 with gastric partitioning. The write up from the doctor :
 

Is a 48-year-old female who has lost a total of 125 pounds with gastric partitioning. The patient has now had this three years and has lost all this weight and is stable'. She is now  complaining of excess skin of her lower abdomen, legs and buttocks. Due to the extreme weight loss, she has lost her skin integrity and now has excessive skin folds of her abdomen and thighs and buttock area. I do not feel any further weight loss or conservative therapy will be of any benefit.  

 

I am now recommending a lower body lift with medial thigh lift which can be done in two different stages. I do not feel any other therapy would be of benefit. Therefore, if this could be approved, it could be done as an outpatient..

The write up had no medical terms as in:Hypertrophic skin condition, intertrigo with candidiasis.
The doctor submitted these code: ICD 9:278.1 and CPT: 15830,15832-50,15865
Tricare disapproved the request saying "its not covered" and they (Tricare) called it Factual.
I was wondering if anybody had any luck in the appeal process and / or are there different codes that can used to do the same surgery...tummy tuck etc.......what about the ICD Code?? I have no idea...but I do know they have done this procedures before.

Any and all information will be greatly appreciated....willing to travel to a Tricare Doctor who can get these approved!!

Ciao~
Brad


BTW the write is for my wife...not me.....:)

It is extremely difficult to get Tricare to cover plastics and usually only done under certain cir****tances. I know they will do a panni lift(not tummy tuck) if she is having rashes and so forth under the skin. As for a thigh lift, I honestly have not heard of them covering one.

Make an appt at your MTF with your PCM and get a referral to see a surgeon at a MTF. I had my breasts done this way, as MTFs operate separate from TriCare and the approvals are at the discretion of the surgeon.