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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.

 

this is so great..i am very happy..i hope it helps anyone who needs it! as much as it has helped me

Hi Missjessicap and OH Group Members,

Congratulations!!  Your OH Group is one of the featured groups on the Groups home page.  You can check it out at:

www.obesityhelp.com/group/

Thank you for this special group you have created that is so supportive of  military spouses.

Thanks, Cathy

thank yall for replying..i just had my first visit with the surgeon and thats exactly what they did..thanks..now i have my list of things to do..so keepin my fingers crossed..thanks

Here's how it happened for me and I'm Tricare Prime.
I went to my civilian PCP and told her I was interested in the WLS, she put in a referral.
Days later I received a letter saying to call for my Orientation.
Attended an Orientation at the Naval Hospital, a couple of weeks later met w/a surgeon (with documentation of the diets I've been on for the past couple of years), she gave me task to complete like ultrasound, Chest Xray, Psych, and Nutrition. Now I'm waiting to see the surgeon again for her to go over my results and to set a date.

None of my diets were monitored. I told my PCP the diets that I was on and she wrote it on her letterhead and I submitted to my surgeon.

I hope that helps.

Amy