Question:
Why isn't Tricare covering Lap RNY and will only pay for open?
Anyone know why Tricare isn't paying for Laproscopic RNY anymore? My daughter was turned down but was told by the sugeron's office that she can have it done open and they will cover it. It seems that the cost is the same since the Lap has an overnight stay with minimal complications and the open the stay is 2 - 3 days. They covered mine almost a year ago and several other ppl that I know. What has changed their minds?? — jenafwife (posted on April 28, 2004)
April 28, 2004
I had mine done lap 7 months ago, no problem. I stayed in the hospital for
4 days, though, because I live two hours from the hospital I had the
procedure done in-better safe than sorry. BUT ANYWAY! If they've changed
the policy, it's been since then...did they say why they turned her down,
or are y'all assuming it's because it's lap? Perhaps the surgeon she's been
seeing declines doing lap on Tricare patients because he/she is not
satisfied with the reimbursement Tricare offers? Maybe Tricare pays more to
the surgeon with open surgery? I'm just throwing ideas out there, as I have
no idea why they wouldn't cover lap. I don't believe they cover the band
(could be wrong), is she trying for the lap-band procedure instead of the
RNY? Hmmm, this is definitely a thinker, I hope someone else can explain
this! Tell your daughter to keep her chin up, we're on the case! :)
— jenn_jenn
April 28, 2004
It probably has to do with the greater complications that can go with a LAP
because they cannot see as clearly what they are doing. After the
publicized deaths out east, I forget which hospital but it was a major one,
they changed their policy to only do opens. Aside from the scar it is by
far the safest. My scar is gone now anyway as PS cut it away and the new
scar is so much nicer looking - just a line.
— zoedogcbr
April 28, 2004
Just wanted to pop in and clear up a very common misconception and Chris,
please don't think I'm disparaging your comments - I respect everyone's
opinions but actually some of the facts you have stated are wrong. First
with LAP surgery you can see MUCH better even though you're not physically
looking inside someone's abdomen. This is because you are seeing
everything on a large television screen and there's no blood and it's much,
much clearer. I was amazed the first time I observed a LAP procedure on how
much easier it was to see things! Further, an open surgery is actually NOT
by far the safest method. With an open surgery there is greater risk of
incisional hernia, bleeding etc. LAP surgery has a much easier recovery
period than open. In our talks with Blue Cross regarding the Lap Band they
are still considering it experimental even though the FDA approved it over
two years ago. I think the same is true with some insurance companies
about Lap RNY. They still consider it experimental or investigational when
it's been successfully done for years now. Chris is correct, however, when
he mentions the two high profile mortalities on the East Coast. I think
this left some insurance companies feeling "snake bit". But
anyway, just wanted to let you know that the view of the surgical field is
clearer with a LAP surgery - believe it or not - and OPEN is not
necessarily the safest way to go. Both have risks and benefits. I
actually had to have mine open and would do it again in a minute! Hope I
didn't offend anyone. Best wishes!
— ronascott
April 29, 2004
I had my LAP RNY three weeks ago and Tricare paid for it.
— Sara H.
April 29, 2004
I had Lap RNY on April 6 and Tricare paid for it. My husband is active duty
Navy. You should not be having trouble. Maybe its best to go to your
nearest Family Services and find out.
— [Deactivated Member]
April 29, 2004
They said that the LAP procedure was still experimental and they will only
cover the open RNY. It can't be the surgeon since they are having to refer
her to a different Dr since this one only does it LAP. It must be whoever
was approving the case since obviously there are others that are having it
done thru tricare. She is now trying to decide to appeal the decision but
that could take 90 days or just go and have it done open and worry about
scarring later. I spoke to an OR nurse that said doing it open is like
trying to do surgery by digging a hole in the sand. They have to keep the
fat and other tissues back to see what they are doing. With the LAP its
easier to see. The skill in using the instruments is where the Dr's skills
come in. Thank you for all your answers.
— jenafwife
April 29, 2004
Rona, You did not offend me but what I was quoting was my surgeon. What
you state is correct in most cases. However, my surgeon will only do open
on the SMO because it is quicker and it is the best way to make sure
everything is fine before closing. He wants us off the table as quick as
possible and an open provides that. I totally agree on the recovery
time/issues and the future possibility of incisional hernias, but at the
time they are working on a SMO that is the least of their worries. First
they want to get you in and out of surgery alive. Then one can worry about
the recovery and hernias. I wanted LAP very bad, as that's how I had my
gallbladder removed in 1994, but the surgeon would not even entertain it
with a BMI of almost 65. So I had to make a choice and I chose that
surgeon. His track record and the fact that he is a top notch trauma
surgeon were enough for me to accept an open. I do not regret it at all.
I no longer have the WLS scar but even if I did I'd still do it over again.
— zoedogcbr
April 29, 2004
Have you checked with your Tricare office about coverage? I have Tricare
Prime, hubby is Retired Navy, I had my surgery in Seattle on 2/5/04, 5 day
hospital stay & Tricare covered it.
Marj
— MarjN
May 1, 2004
I had lap RNY on April 14th and tricare paid for mine. My hubby is active
duty Air Force. I have heard that Tricare will not pay for Lap if your BMI
is over a certain number?? I would definately check into this!
— cedsangel
May 2, 2004
I had my RnY Distal LAP surgery on the 5th of Feb.,2004 (nearly 3 months)
and Medicare and Tricare covered every penny of my surgery, dr.s' fees,
including my physic evaluation. My husband is retired Army for 25 years.
— cindirella
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