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Tricare – Weight Loss Surgery Requirements

In Am I Covered by admin

Tricare covers weight loss surgery. To qualify for coverage of weight loss surgery, your policy must include coverage. Not all policies include coverage. To find out if you policy includes coverage, please talk directly to Tricare.

Assuming you are covered, Tricare has a single policy that sets the criteria for all of the Tricare regions for weight loss surgery. The requirements are below.

Tricare Pre-Approval Requirements

Tricare covers weight loss surgery when the following requirements are met:

  1. You are at least 18 years of age and you have completed bone growth.
  2. You were unsuccessful with non-surgical medical treatments for obesity.
    1. You must be able to show that you tried and failed programs such as Jenny Craig. This should include regular doctors visits or other documentation of the program and weigh-ins.
    2. Weight loss medication alone does not qualify as a weight loss program.
  3. Your Body Mass Index (BMI) is greater than 40 or:
  4. Your BMI is between 35 and 39.9 and you have at least one clinically significant co-morbidity.
    1. These can include diabetes, hypertension, obstructive sleep apnea, cardiovascular disease and/or pulmonary hypertension.

Procedures Covered by Tricare

Tricare does not cover the following procedures:

  • Sleeve gastrectomy
  • Biliopancreatic bypass
  • Gastric wrapping or open gastric banding.
  • Any experimental procedure such as gastric bubble or balloons.

Note: Tricare does not cover doctor office visits for the treatment of obesity. Tricare also does not cover non-surgical procedures for weight loss. It does not cover gym memberships, or weight loss programs such as Jenny Craig or Weight Watchers. Diet and nutrition counseling is not covered by Tricare.

Where do I Need to Have Surgery?

As with most procedures, you will be required to have surgery at an approved VA facility or other network providers in the TRICARE region where you are enrolled.

Note About Bariatric Surgery for Military Personnel

Health Affairs Policy 07-006 states that “Bariatric surgery represents a major and permanent change in your digestive system that requires strict adherence to a specific dietary regimen that may interfere with operational deployment. A history of bariatric surgery is already a bar to military service and receiving bariatric surgery while on active duty may be grounds for separation.”

What About Cosmetic Surgery to Remove Excess Skin After Weight Loss Surgery?

After you’ve had weight loss surgery and lost weight you may have excess skin. Surgery to have excess skin removed after weight loss surgery may be covered if it is a medical necessity. If you have large folds of skin that become infected, irritated or otherwise cause health problems that your physician treats, then cosmetic (plastic) surgery is typically covered by Tricare to remove excess skin. However, if the removal of excess skin is solely for cosmetic reasons, then Tricare will not cover the procedure.

Tricare’s Weight Loss Surgery Policy

You can find Tricare’s weight loss surgery policy here.

 

 

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