I just wanted to let others know of my experience with Tricare Prime and paying for my RNY.  When I was researching I read some hopeless comments so I wanted to let others know my story and hopefully that will help them and give them some peace of mind trying to have theirs approved through Tricare.  I used a civilian hospital that was a ceter of excellance for bariatric.  Our closest MIL Hospital is in Utah or Washington. 

I have other health insurance, but we knew from the start it had an exclusion for weight loss surgery. I had to have my lapband removed, I was in the process of having a hysterectomy so my GYN surgeon and my RNY surgeon teamed up and we had my lapband removed while I had the hyst done.  Tricare paid the RYN surgeon fee to have my band removed since my Primary insurance would not touch it.  They also itemized my bill from the hospital and Tricare paid the fees that my OHI would not due to being specific for the lapband removal.   We  started working on the Tricare requirements to be approved for Tricare for RNY.  At that time they required 6 months of physician supervised weight loss attempt.  I took a few months to recover from hyst and then started they 6 months of supervised visits.  Neither my primary or Tricare would pay for weight loss appts. but my primary Dr. coded my visits in regards to my high blood pressure and edema of the feet and other issues, both insurances then paid for my appts.   In October the RNY surgeon insurance manager submitted the approval to my primary insurance, even though we knew they would deny the approval, we needed it in writing to submit to Tricare for their approval.  Once we had that they submitted to Tricare, they denied the approval "due to having other health insurance" they would not approve.  We figured this would happen, so the insurance staff followed up with a detailed email and phone call to a specific dept @ Tricare and explained what was going on and what was needed.  Within a few days we had written approval from Tricare.  I had my surgery and then I received my first EOB from Tricare denying the charges..they needed the charges to be submitted to my primary and denied before they would pay them, even though they already they already had a blanket denial from the primary from requesting the approval.. I had the hospital and surgeon submit to the primary and then resubmit with the denials to Tricare.  Yesterday I received my EOB from Tricare they have paid the hospital and surgeon charges and I owe 25.00 as my co-share.  I still have 1 bill out that has to go through the primary denial and then resubmit process but it should be paid as well with a 25 co-share.  It was a process but not too bad and overall to pay 50.00 total for a 33k surgery I can jump through a few hoops and wait a little. 

Send me a message if you have any questions.  Hope this helps someone.

Jaq 

There are many people, members and non-members, that come to the OH community wanting assistance to have weight loss surgery.  One of the challenges many people encounter is "The Medicaid Maze" so we wanted to provide information about the difficulties for those people and from two leading bariatric surgeons. 

We welcome your experiences by leaving a comment at the end of the article. 

I have Anthem Blue Cross and am in need of revision or conversion surgery. My plan benefit coverage states the criteria for weight loss surgery: bmi, 12 months medically supervised diet program, etc. However, the plan booklet does not give criteria for weight loss revision. It does not mention revision at all. I had the sleeve done in 2010 and 2 months later I was having chemo for breast cancer. With the excessive vomiting that resulted, my sleeve has stretched (surgeon described it as an orange sitting on top of a banana). I have acid reflux, sleep apnea, joint pain, and have regained 70lbs. The surgeon also stated that the sleeve dilation puts me at risk of ulcers.

Anyway, Blue Cross's "Medical Policy" for bariatric surgery does list the criteria for revision (one is pouch dilation due to excessive vomiting) and my revision would qualify as medically necessary. My surgeon has included my situation in his progress notes.

Since my plan does not specifically mention criteria for revision but the insurance's medical policy does, how will Blue Cross base it's decision? I'm gearing up for an appeal via State of CA. I'm so stressed...thanks.

Dr. Alvarez has shared with us the latest episode on www.obesitychat.com or you can go to it directly:

http://guillermoalvarez.podomatic.com/entry/2014-07-15T09_03 _17-07_00

Does anyone know which DS surgeons accept Medicare assignment?