military spouses sharing experinces
TRI CARE Policy Manual Ch 4 Sec 13.2
If anyone would like a copy of this please send me a message and I can email it you the original.
- It covers "Surgery for Morbid Obesity" Insurance codes, Policy, exceptions and exclusions.I. CPT1 PROCEDURE CODES
43644, 43770 - 43774, 43842, 43846, 43848
II. HCPCS PROCEDURE CODE
S2083
III. DESCRIPTION Morbid obesity means the body weight is 100 pounds over ideal weight for height and
bone structure, according to the most current Metropolitan Life Table, and such weight is in
association with severe medical conditions known to have higher mortality rates in
association with morbid obesity; or, the body weight is 200% or more of ideal weight for
height and bone structure.
IV. POLICY
A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded
gastroplasty is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure and
has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis,
narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic
disorders and severe arthritis of the weight-bearing joints.
2. The patient is 200% or more of the ideal weight for height and bone structure. An
associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because
of complications, requires a second surgery (a takedown).
B. In determining the ideal body weight for morbid obesity using the Metropolitan Life
Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the
weight range. Payment will be allowed when beneficiaries meet all requirements for morbid
obesity surgery including the ideal weight within the newly determined range.
V. EXCEPTIONS
A. Benefits for adjustments to the gastric banding device by injection or aspiration of
saline, including any adjustment-related complications, shall be allowed for patients who
underwent the LAP-Band surgery before the effective date of coverage only if the patient
criteria discussed in paragraph IV.A. were met or would have been met at the time of surgery.
NOTE: TRICARE will not cost-share any complication resulting from the initial surgery,
including band-related complications, for those patients who surgeries were performed prior
to the effective date of coverage. If, however, a complication results from a separate medical
condition, benefits shall be allowed for the otherwise covered treatment. A separate medical
condition exists when it causes a systemic effect, or occurs in a different body system from
the noncovered treatment.
B. Documentation must be submitted that gives the patient’s history and shows that the
patient met or would have met the criteria for the morbid obesity benefit at the time of
surgery. The contractor shall conduct a medical review to assure compliance with paragraph
IV.A. Where necessary, additional clinical documentation shall be obtained as part of this
review.
VI. EXCLUSIONS
A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction.
B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of
morbid obesity is unproven (CPT2 procedure codes 43645, 43845, 43847, or 43633).
C. Gastric bubble or balloon for treatment of morbid obesity is unproven.
D. Gastric wrapping/open gastric banding (CPT2 procedure code 43843) for treatment
of morbid obesity is unproven.
E. Unlisted CPT2 procedure codes 43659 (laparoscopy procedure, stomach); 43999 (open
procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and
omentum) for gastric bypass procedures.
VII. EFFECTIVE DATES
A. Laparoscopic surgical procedure for gastric bypass and gastric stapling
(gastroplasty), including vertical banded gastroplasty are covered, effective December 2,
2004. revised jan 22,2010
Bottom line Tricare does not cover VSG as a first time WLS.
It is being performed at some MTF's
Hope this helps someone.
- It covers "Surgery for Morbid Obesity" Insurance codes, Policy, exceptions and exclusions.I. CPT1 PROCEDURE CODES
43644, 43770 - 43774, 43842, 43846, 43848
II. HCPCS PROCEDURE CODE
S2083
III. DESCRIPTION Morbid obesity means the body weight is 100 pounds over ideal weight for height and
bone structure, according to the most current Metropolitan Life Table, and such weight is in
association with severe medical conditions known to have higher mortality rates in
association with morbid obesity; or, the body weight is 200% or more of ideal weight for
height and bone structure.
IV. POLICY
A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded
gastroplasty is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure and
has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis,
narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic
disorders and severe arthritis of the weight-bearing joints.
2. The patient is 200% or more of the ideal weight for height and bone structure. An
associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because
of complications, requires a second surgery (a takedown).
B. In determining the ideal body weight for morbid obesity using the Metropolitan Life
Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the
weight range. Payment will be allowed when beneficiaries meet all requirements for morbid
obesity surgery including the ideal weight within the newly determined range.
V. EXCEPTIONS
A. Benefits for adjustments to the gastric banding device by injection or aspiration of
saline, including any adjustment-related complications, shall be allowed for patients who
underwent the LAP-Band surgery before the effective date of coverage only if the patient
criteria discussed in paragraph IV.A. were met or would have been met at the time of surgery.
NOTE: TRICARE will not cost-share any complication resulting from the initial surgery,
including band-related complications, for those patients who surgeries were performed prior
to the effective date of coverage. If, however, a complication results from a separate medical
condition, benefits shall be allowed for the otherwise covered treatment. A separate medical
condition exists when it causes a systemic effect, or occurs in a different body system from
the noncovered treatment.
B. Documentation must be submitted that gives the patient’s history and shows that the
patient met or would have met the criteria for the morbid obesity benefit at the time of
surgery. The contractor shall conduct a medical review to assure compliance with paragraph
IV.A. Where necessary, additional clinical documentation shall be obtained as part of this
review.
VI. EXCLUSIONS
A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction.
B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of
morbid obesity is unproven (CPT2 procedure codes 43645, 43845, 43847, or 43633).
C. Gastric bubble or balloon for treatment of morbid obesity is unproven.
D. Gastric wrapping/open gastric banding (CPT2 procedure code 43843) for treatment
of morbid obesity is unproven.
E. Unlisted CPT2 procedure codes 43659 (laparoscopy procedure, stomach); 43999 (open
procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and
omentum) for gastric bypass procedures.
VII. EFFECTIVE DATES
A. Laparoscopic surgical procedure for gastric bypass and gastric stapling
(gastroplasty), including vertical banded gastroplasty are covered, effective December 2,
2004. revised jan 22,2010
Bottom line Tricare does not cover VSG as a first time WLS.
It is being performed at some MTF's
Hope this helps someone.
we have had Tri care for years ( my husband is active duty)
As far as the 6 month diet, I think that is up to your primary care physician. I decided to pursue WLS in Sept, had my appt with my pysician in Oct. Then Tri Care had a checklist that my Dr had to complete (included nutrition appt, psych eval etc.) I submitted my checklist and paperwork to Tricare in Nov and my apptwith my surgeon was booked for Jan.
My surgeon books his surgery's at the consult, I had my consult Jan 18 and my surgery was Feb 4.
It was a quick process for me, but I think this differs from area to area. I am overseas.
If you can find someone in your area who had had WLS with the surgeon you choose, they will be able to explain how "your surgeon" does it.
My advice, make copies of all your paperwork! and when you go to the doctor the visit explain why you want WLS (health, quality of life, unsuccessful on your own at losing etc.)
My PC 2 years ago wouldn't discuss WLS surgery with me, he told me I wasn't a canidate! (I was) If that is the case switch Doctors! Find a Dr that will support you, it makes a big diffrence (they're the one signing off on the paperwork!)
best of luck to you!
As far as the 6 month diet, I think that is up to your primary care physician. I decided to pursue WLS in Sept, had my appt with my pysician in Oct. Then Tri Care had a checklist that my Dr had to complete (included nutrition appt, psych eval etc.) I submitted my checklist and paperwork to Tricare in Nov and my apptwith my surgeon was booked for Jan.
My surgeon books his surgery's at the consult, I had my consult Jan 18 and my surgery was Feb 4.
It was a quick process for me, but I think this differs from area to area. I am overseas.
If you can find someone in your area who had had WLS with the surgeon you choose, they will be able to explain how "your surgeon" does it.
My advice, make copies of all your paperwork! and when you go to the doctor the visit explain why you want WLS (health, quality of life, unsuccessful on your own at losing etc.)
My PC 2 years ago wouldn't discuss WLS surgery with me, he told me I wasn't a canidate! (I was) If that is the case switch Doctors! Find a Dr that will support you, it makes a big diffrence (they're the one signing off on the paperwork!)
best of luck to you!
I am new to this website and team. I am interested in having WLS, I live in Okinawa, Japan. I know that I will have to be referred out. I am miresable in my body right now and I hope that my PCM will understand this. He currently treats me for depression and I know that my weight is the cause of my depression and joint pain. I am interested in knowing how you feeling and what types of issues if any that you maybe having. I hope I am not being to nosey or anything but I am just trying to see if this is right for me. I know in my mind that it is. I do hope everything is going well with you so far.
Thank you,
Erica
Thank you,
Erica
Hi Erica,
I had considered weight loss surgery for years. I,ve had many failed attempts at trying to lose on my own.. My PCM last year wouldn't discuss it with me.My husband did not agree with WLS so I waited another year and unfort put on 20 pounds.
After a long discussion with my husband and his support I contacted my new PCM in October and started the process for WLS. Since my BMI was over 40 and I was more then 100 pounds overweight I was eligible for WLS. I had a friend who had gone through it 18months earlier and her success inspired me.
SInce the surgery (I am 3 weeks out) i feel great. I have lost over 25 pounds in a month (a few pounds were pre op) and I am following my surgeons plan.
I have the support of my husband and a few friends and I am determined to do this the right way. The fear of complications also keeps me in line!
My advice is research, research, research. Make sure your husband is supportive and talk to your PCM. If you meet the criteria, he should start the process for you. There will be nutrion appointments and pschy eval(s). Stay positive and Good luck!
