Question:
Has anyone had success with revision surgery through primcare?
Hi i am writing this for my best friend who needs revision surgery. She had the silastic ring and it now has a disruption. Her new insurance won't pay but, she also has tricare prime. She wants to get the BPD/DS like I did and wanted to know what the chances are that primecare (military ins) will approve her. What are their requirements and how hard is it to get approved through them? Could some of you wonderful friends help me out here? I love her to death and she is so down about this weight gain due to the disruption. Thanks — BARBARA R. (posted on March 25, 2000)
March 25, 2000
It is to my understanding that Tricare Prime will approve your friend for
this procedure. I could be wrong because she did not go through them
initially but I am almost positive that they will help her. She needs to go
and visit her Primary Care Manager at the military hospital and ask that he
submit a referral for her for this. I was just approved by Tricare Prime on
March 22 for open RNY. They should approve her. If she has another
insurance company in addition though this may be where she might have a
problem with Tricare.
— Becky R.
March 25, 2000
It is to my understanding that Tricare Prime will approve your friend for
this procedure. I could be wrong because she did not go through them
initially but I am almost positive that they will help her. She needs to go
and visit her Primary Care Manager at the military hospital and ask that he
submit a referral for her for this. I was just approved by Tricare Prime on
March 22 for open RNY. They should approve her. If she has another
insurance company in addition though this may be where she might have a
problem with Tricare.
— Becky R.
March 25, 2000
Tricare Prime should cover providing she meets their stated criteria.
There's no mention in the book about a revision, so it may not matter.
Normally, Tricare is always secondary to other insurance, but if the first
policy has an exclusion, Tricare will become primary. Special note about
Prime - if there is a military facility nearby that offers WLS, she may
need to go through them. No military surgeons offer the BPD/DS...yet. If
she switches to Tricare Standard, she can see anyone she wants, and avoid
the possible hassle of having to prove that the other operation (the one
the military doc does) isn't right for her. I travelled from Virginia to
NYC for surgery, and Tricare Standard covered it. If she chooses to revert
to Standard, I suggest she purchase a supplement. They're readily available
(look in Army/Navy/etc... Times for ads) to anyone and the cost is
reasonable, about $40-50/month on average for good coverage over
Standard.The advantage with Standard is that no referral is necessary, she
goes straight to the surgeon, who then submits the request to Tricare. The
disadvantage is cost...they won't cover everything, unless her doc and her
hospital are full Tricare providers. My doc wasn't, my hospital was, so the
larger part of the bill was covered 100%. Don't know yet how much of the
rest I'll have to pay. I was approved on the first submission, but needed
to provide both a psych and nutritional evaluation. Their stated
requirements are 100lbs or 200% of ideal body weight, or lower weight if
some co-morbids are present. Her local Tricare advisor can provide her the
coverage guidelines and the codes for the various procedures that they'll
cover. Note that no special code exists for BPD/DS, so it's covered by
Tricare as a distal gastric bypass and a partial gastrectomy. Best of luck
to her!
— Duffy H.
Click Here to Return