Tricare Standard for TT

Ramgon
on 2/4/09 10:21 pm - Palmdale, CA

Hello World,

Has ANYONE out there had any luck with Tricare providing a TT and breast work. If so, do you need to have problems with rashes, infections, back pain, etc?

Thanks for your help.

Redhaired
on 2/4/09 10:52 pm - Mouseville, FL

DS on 07/13/06

The regs indicate Tricare will cover a panniculectomy with documentation of medical necessity. But it seems approvals for this are spotty and many have to appeal. But one thing for sure is that you will need to have documentation of on-going problems with skin issues and the like. They are going to be looking for persistent issues that are not responsive to less invasive treatment. This is going to mean getting every rash documented in your medical records. Do not self treat -- at all. You will want to document that problems have lasted awhile.

You can search for the policy at the following link using search term panniculectomy. http://manuals.tricare.osd.mil/ or http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManua ls.DisplaySearchPage&Manual=TO02&Change=76

Red

Ramgon
on 2/4/09 11:01 pm - Palmdale, CA

Thanks, Red. I'm starting my research and documentation early because I know I'm going to want to have this removed as soon as possible. The boobs and tummy look so strange, my husband and I affectionately call it the "alien".

So appreciate your time/help. Do you have Tricare? Is Dr. Anthone the former USC surgeon?

Redhaired
on 2/4/09 11:14 pm - Mouseville, FL

DS on 07/13/06

Yes I have tricare standard. And yes Dr. Anthone was at USC, he has been in Omaha for a few years now.

I think the trick is going to be finding a plastic surgeon that is willing to work with Tricare. The reimbursement rate is so low. I know that when I started looking into plastics I called all of the PS in Orlando that Tricare said accepted Tricare and each one told me they did not accept Tricare for the TT or panniculectomy. I extended my search and found one in Tampa, about 85 miles from here. I am one of the ones that did not get approval. But I had another way to have my surgery so I did not even bother with appealing the decision.

A friend of mine submitted for a LBL. Tricare approved the panni but denied the back part. She is appealing the decision.

Good luck and let me know if there is anything else I can do to help.

Red

Ramgon
on 2/5/09 12:06 am - Palmdale, CA

Thanks for the help, Red. I'm gonna start looking now because I know I'm going to need it. I have moisture already forming.

What I need to know is how "long"(?) does it have to be and from where does one measure?

I'll ask Petra, too.

Thanks again, Ladies!

Redhaired
on 2/5/09 12:25 am, edited 2/5/09 12:33 am - Mouseville, FL

DS on 07/13/06

I found a draft document on the Tricare website a couple of years ago that stated the following. Now bear in mind this was for Europe, it is a draft and it was dated 2005, so I am not sure if it is still relevent. But it does give some specifics about what they may be looking for when reviewing your request.

Red

__________________________________________________________________________

The title of the document is APPROVAL AND NETWORK USE FOR MORBID OBESITY/COSMETIC/PLASTIC SURGERIES IN HOST NATION FACILITIES.

The purpse of the document is:

2. PURPOSE: To establish procedures for referring TOP Prime and Standard beneficiaries to civilian hostnation facilities for cosmetic/ plastic or morbid obesity surgery. These guidelines align TRICARE Europewith CONUS procedures for pre-approval of cosmetic, plastic and morbid obesity surgery. Mechanisms areoutlined for care pre-approval. Key criteria of TRICARE guidelines, referenced above are highlighted: complete current TRICARE Policies can be found on the internet at http://www.TRICARE.osd.mil/TRICAREmanuals/

NOTE: Abdominoplasty and/or removal of the overhanging lower abdominal panniculus are considered cosmetic procedures. TRICARE will not cover these procedures or for repair of a diastasis recti in the absence of a true midline hernia (ventral or umbilical). On rare occasions, abdominoplasty may be considered for coverage with determination of medical necessity. Primary Care Manager must indicate all that apply:

Overhanging pannus below the symphysis pubis

AND

Evidence of skin breakdown; skin rashes or intertrigo recalcitrant to conventional treatment for over 12 months

AND

Evidence of greater than 100 lb weight loss (from peak weight to present) with stabilization of weight in the past 4 months. (the amount may be waived based on height and other considerations)

AND IF Status Post Gastric Bypass Surgery:

At least 18 months from gastric bypass surgery

okiepetra
on 2/4/09 11:55 pm - Lawton, OK

RNY on 04/24/07

Hi there I have Tricare Prime, was denied because I didn't have a rash, panni wasn't hanging low enought and so on, I send in an apeal with pictures of a rash and did a bunch of searching on the web, there are great samples of apeal letters, send it all in and got approved

Petra

Redhaired
on 2/4/09 11:58 pm - Mouseville, FL

DS on 07/13/06

That is great Petra. Did you get a TT or LBL?

Red

okiepetra
on 2/5/09 12:02 am - Lawton, OK

RNY on 04/24/07

I got the panni, cut all the way around, and a re-do on my gastric scar, most of my skin was on the upper belly, so far I am very happy with it, still swollen on the lower part, be ready for a fight with Tricare, like I said, they will deny you hoping you go away,

Ramgon
on 2/5/09 12:07 am - Palmdale, CA

I won't go away, but where does one measure the panni from, and how long must it be? I'm already having moisture and the pressure put on a surgial scar from a surgery I had a few years ago is stretching, pulling and feels like it's opening.

Thanks and appreciate your time/help.

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