Question:
Tricare & Medicare

A friend of mine needs GB Doc says Yes... Also said Medicare will not pay ... she also has a goverment Ins. Tricare what should she do now? Thanks    — Flo (posted on March 31, 2006)

March 30, 2006
What is a GB doctor?? Also you need to have your friend talk for herself. Is she wanting to have WLS? TiCare pays for WLS, but this is something she needs to address.
   — Steve Cohen

March 31, 2006
Medicare covers WLS. Her surgeon may not be on the approved list, so they will not pay for him to do the surgery. Here is the Medicare statement: "Decision Summary The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. CMS has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements in effect on February 15, 2006). A list of approved facilities and their approval dates will be listed and maintained on the CMS Coverage Web site at www.cms.hhs.gov/center/coverage.asp, and will be published in the Federal Register. The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary; therefore, the following are non-covered for all Medicare beneficiaries: open vertical banded gastroplasty; laparoscopic vertical banded gastroplasty; open sleeve gastrectomy; laparoscopic sleeve gastrectomy; and open adjustable gastric banding. The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged - Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8). Modification of the current policy on obesity, found in section 40.5 of the NCDM, will include a reference to the covered surgical procedures and will merge the obesity policy with the final bariatric surgery policy. The modified obesity policy will read as follows (emphasis added to the new language within the policy): Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. Treatments for obesity alone remain non-covered." Source:http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160 Find her a surgeon at a Center of Excelence and let Tri Care and Medicare figure out who pays for what. Best wishes to your friend. Joshua
   — nursenut

March 31, 2006
Medicare will not approve or disapprove any surgery. With Medicare, Tricare will not give a approval, but both insurances do pay for the Gastric Bypass, not Lap band usually or in most cases the Lap procedure. First, you need to call Tricare and get a list of surgeons, makes some calls until you find a gastric bypass surgeon from Tricare list, and ask if they accept both Medicare and Tricare. If yes, you can make a consultation appt yourself, because you have Medicare, no pre-approvel is required, if you only had Tricare, then you would have to have your pcp send to Tricare for auth to see a surgeon for a consult, but you skip that part because Medicare does not require pre-auth for an appt. Both insurance do pay for gastric bypass, if you only had Medicare it would be harder, both you have two insurances that both pay, so find the right surgeon, do not take NO for a answer, be pro-active............Make that call to Tricare and Good Luck.
   — cindy

March 31, 2006
My husband is in the Military and we got Tricar insurance there paid my RNY right away.
   — Babylove05

March 31, 2006
tricare is also considering covering the DS, I have aappeal before the secretary of defencese for Health ,General Granger concerning the DS. now as I cannot have a rny due to service connected injuries.
   — walter A.

April 6, 2006
In responce to STEVE. Steve! GB stands for GASTRIC BYPASS ....I wasn't talking for her.. She has no computer so I am getting much needed info for her... I see nothing wrong with helping a friend in need... Yes she wants WLS... That is what this site is all about. I would have guessed you would know the answers to all your own questions as you said on your profile you work doing this type thing. She will be addressing this to the Doctors Not me..And if she ask me to go along and help her ask questions I would do so. She had a stroke and cant speak well as it is... As I said she needs help and I will be there for her. I would hope that you are much kinder to your patients...
   — Flo