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
Click Here to Return