Tricare Standard for TT
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
So appreciate your time/help. Do you have Tricare? Is Dr. Anthone the former USC surgeon?
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.
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
Evidence of skin breakdown; skin rashes or intertrigo recalcitrant to conventional treatment for over 12 months
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
Thanks and appreciate your time/help.
Based on what I've read and have been told, another problem is finding a surgeon that will accept Tricare. The reimbursement is so low, that even those that Tricare refers to, sometimes deny an appointment fo consult because they decided not to accept it. That happened to me w/ my WLS doctor.
Thanks so much for your help and I will keep the world posted.
The above poster was correct and you have to fit in the three requirements to get it approved. I didn't have any problems at all but I'm having it done at a Navy hospital.
on 3/9/09 1:35 am
I have had 4 babies in 5.5 years. With a pan. that hangs past my pubic area....haven't measured, but can't see pubic area at all it hangs so low. I'm 191, 5'1, last baby born in August. I have an umbilical hernia from the pregnancies, all delivered c-sections. Obviously, I need to shed some lbs to be considered. I have constant rashes, ulcers, which I have been self treating, the wetness contributed to a massive infection with my last delivery....I had to go back to the hospital for 10 days and almost died...had to have wound heal from the inside out. I can meet the criteria over the next year.... there is no way I can loose 100 lbs...I would look like a waif. 150lb. is my goal. Does having the hernia help my case with tricare? Oh I would appreciate your advice...so I know how to take on the beast! (tricare).
THANKS! And good luck with all of your surgeries/endevors!