Tricare denied me a second time
So, I was denied again. Seems Tricare doesnt like any of the codes my Dr. is using. I asked the case mgr what code the Dr. could use and she said we cant tell the Dr. what to do..... So he is using the term gasrectomy which is a code they dont cover. When I called the nurse she said he was going to remove the portion of my stomach when he wou;d fix my staple line. See Tricare doesnt cover surgery more than once per lifetime. I am trying to make then fix the hole in the staple line. I am about at the end of my rope......
Tricare is not my provider but they most certainly DO cover revisions as they deem appropriate.
You might want to sit down with your surgeon's patient care coordinator. Sounds like there probably is a better, more appropriate code they could use. It sounds like you aren't actually having a revision but a repair.
Your trying to have them fix the whole in the staple line but, he is actually doing a VSG at the same time correct? The current code for the sleeve is 43775.
CPT 43775 - Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
What is he using?
BAND REMOVED 9-4-12-fought insurance to get sleeve and won! Sleeved 1/22/13! Five years out and trying to get that last 15 pounds back off.
Just saw this today and thought it would give you hope. Its from http://www.ama-assn.org/amednews/2012/04/23/bisa0423.htm
"Twenty-five percent of patients considering bariatric surgery are denied coverage three times before approval, according to the ASMBS."
BAND REMOVED 9-4-12-fought insurance to get sleeve and won! Sleeved 1/22/13! Five years out and trying to get that last 15 pounds back off.
He used code 43632 0 gastrectomy partial ds disdtal with gastrojejunostomy. When i spoke with the nurse i thoughjt she was submitting it for more of a repair. I sent them the papers saying Tricare does not cover DS, Sleeve or gastrectomy. So he needs to find a code for repair and none of the words i just mentioned. It did say Tricare limits surgery and revision to one in a lifetime. But it goes on to say that i have a partial obstruction that may be covered but it is clear from the documentation that the objective is to do a bariatric procedure. I even asked tricare of they could give me a code to tell him to use for the repair that would be covered and they said they cannot do that.
Do you have a partail obsteuction? I had my surgery in 2000 and then 4 emergency surgeries afterwards. I had a revised during the second to last one. But I was only 117 lbs. then 3 years later I had a stomach perforation. Now I am dealing with a 4 bowel obstuction. So I am asking is it for weight loss. Because after my fist surgery I drop 147 lbs in one year. And 13 years later I still obey all the rules I have not had a soda in 13 years. I eat 1/3 of what I did. So just wondering why you want the revision. I weigh 97lbs. I was at 117. until the perforation that I was life flighted for. So, if it is something you can alter by your habits? o is it somethig you doctor is requesting. And remember Tricare doesnt have any major Medical hospital in Illionis.
Is it medically neccesary?
Tricare will not cover VSG at all. No word of when they will cover it, even though Medicare began covering it in July 2012. The only way to get it covered is to have the procedure done at a MTF. I have spent hours on the phone and internet confirming this in the last two days. They will cover lapband and RNY by a private physician at a private facility, but not VSG. There is no appeals process to override a denial for VSG with Tricare because they maintain that it is not a proven method. SO FRUSTRATING!!! Good luck.
