Hello all,
I had WLS 2007 and lost a total of 125 with gastric partitioning. The write up from the doctor :
 

Is a 48-year-old female who has lost a total of 125 pounds with gastric partitioning. The patient has now had this three years and has lost all this weight and is stable'. She is now  complaining of excess skin of her lower abdomen, legs and buttocks. Due to the extreme weight loss, she has lost her skin integrity and now has excessive skin folds of her abdomen and thighs and buttock area. I do not feel any further weight loss or conservative therapy will be of any benefit.  

I am now recommending a lower body lift with medial thigh lift which can be done in two different stages. I do not feel any other therapy would be of benefit. Therefore, if this could be approved, it could be done as an outpatient..

The write up had no medical terms as in:Hypertrophic skin condition, intertrigo with candidiasis.
The doctor submitted these code: ICD 9:278.1 and CPT: 15830,15832-50,15865
Tricare disapproved the request saying "its not covered" and they (Tricare) called it Factual.
I was wondering if anybody had any luck in the appeal process and / or are there different codes that can used to do the same surgery...tummy tuck etc.......what about the ICD Code?? I have no idea...but I do know they have done this procedures before.

Any and all information will be greatly appreciated....willing to travel to a Tricare Doctor who can get these approved!!

Ciao~
Brad


BTW the write is for my wife...not me.....:)

Anyone out there get the VSG through health-net medi-cal?? If so what were their specific requirements? How long did it take to get the approval you needed? I fit all criteria for WLS (BMI of 46,high cholesterol,high trigycerides,early onset diabetes,possible sleep apnea-getting sleep study next week) except I have no documented diets from the dr. But I have dieted numerous times throughout the yrs. The weight always comes back. I have researched all WLS options and feel that I need the VSG bc Ibuprofen is th only thing that takes my pain away for ANYTHING and I really don't want to have problems down the road with taking it after the rny and no way in heck is anyone putting any type of band on my stomach,too many horror stories for all that...lol. Anyway,some insight would be awesome! Thanks!

I have priority health POS, just sent my documents last friday. still waiting for the answer.

But let me tell you this... Priority health will approve you right away if you meet their requirments.

They are very strict. I've been doing this for 10 months now

Goodluckkk !!!!