Tricrare Manual

Just in case anyone wants to take a copy of the Changes regarding Lap Band to their Dr.s appointments, here is the link to the PDF file - it is quite awkward to manipulate - so I copied and pasted the text into this post also.
Once it pulls up, choose "Section Affected by Change 66" Then Download the one named "C4S13_2".

I also saved it as an attachment at the bottom - I hope it works.

TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002
SURGERY
C-66, December 10, 2007
CHAPTER 4
SECTION 13.2
SURGERY FOR MORBID OBESITY
ISSUE DATE: November 9, 1982
AUTHORITY: 32 CFR 199.4(e)(15)
I. CPT1 PROCEDURE CODES
43644, 43770 - 43774, 43842, 43846, 43848, 43886 - 43888, S2083
II. DESCRIPTION
Morbid obesity means the body weight is 100 pounds over ideal weight for height and
bone structure, according to the most current Metropolitan Life Table, and such weight is in
association with severe medical conditions known to have higher mortality rates in
association with morbid obesity; or, the body weight is 200% or more of ideal weight for
height and bone structure.
III. POLICY
A. Gastric bypass, gastric stapling or gastroplasty, to include vertical banded
gastroplasty is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure and
has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis,
narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic
disorders and severe arthritis of the weight-bearing joints.
2. The patient is 200% or more of the ideal weight for height and bone structure. An
associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because
of complications, requires a second surgery (a takedown).
B. In determining the ideal body weight for morbid obesity using the Metropolitan Life
Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the
weight range. Payment will be allowed when beneficiaries meet all requirements for morbid
obesity surgery including the ideal weight within the newly determined range.
1 CPT codes, descriptions and other data only are copyright 2005 American Medical Association. All rights
reserved. Applicable FARS/DFARS Restrictions Apply to Government use.
TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002
CHAPTER 4, SECTION 13.2
SURGERY FOR MORBID OBESITY
2
IV. EXCLUSIONS
A. Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction.
B. Biliopancreatic bypass (jejunoileal bypass, Scopinaro procedure) for treatment of
morbid obesity is unproven (CPT2 procedure code 43645, 43845, 43847, or 43633).
C. Gastric bubble or balloon for treatment of morbid obesity is unproven.
D. Gastric wrapping/open gastric banding (CPT2 procedure code 43843) for treatment of
morbid obesity is unproven.
E. Unlisted CPT2 procedure codes 43659 (laparoscopy procedure, stomach); 43999 (open
procedure, stomach); and 49329 (laparoscopy procedure, abdomen, peritoneum, and
omentum) for gastric bypass procedures.
F. Adjustable gastric band (open or laparoscopically) (CPT2 procedure codes 43770 -
43774, 43886 - 43888, and 90772).
V. EFFECTIVE DATES
A. Laparoscopic surgical procedure for gastric bypass and gastric stapling
(gastroplasty), including vertical banded gastroplasty are covered, effective December 2,
2004.
B. Laproscopic adjustable gastric banding is covered, effective February 1, 2007.
- END -
2 CPT codes, descriptions and other data only are copyright 2005 American Medical Association. All rights
reserved. Applicable FARS/DFARS Restrictions Apply to Government use.
C-66, December 10, 2007

Attached Files

C4S13_2.pdf (38.7 KB, 29 views)