Tricare denied-says VSG is experimental

Anyone had any experience with Tricare Standard. We are retired military and Tricare is my secondary insurance. My primary insurance--Cigna has paid for my surgery, but Tricare is denying payment on the remaining balance stating the surgery is experimental!!
How is the world can it be experimental when other companies recognize it as legitimate??? I am going to file an appeal with Tricare. Any suggesions for those of you with Tricare?

read my blog which contains my winning appeal letter on the issue of investigational status. its under the section entitled four months out. the research needs to be updated and you need to look at your own policy definition of experimental. what is experimental is not black and white but is the subject of much dispute and litigation so by all means appeal. i don't know much about tricare but they have to have definitions in their policy and guides about this so get copies of it and get started. your state insurance department may have a consumer affairs division to help you. Diane

I had it done through Tricare at Wilford Hall!!  My husband is active duty though so I think we have Tricare Prime.  I would appeal!! That's crap!!!

Appeal, appeal, appeal! 

I don't have Tricare, I have Health Net. I read the sample letters here and had every doctor write a letter in support . I mean every doctor, even your eye doctor.

Good Luck!

check out my blog for lots of info about how the sleeve is now a standard of care. Good luck!

I would appeal them. I am in the process of gettiing sleeved at a military hospital. Another lady said she got it done at Willford Hall. I would tell them this hospital for sure does it, and Ft Bliss William Beaumont does it for sure. It's doesn't make since as experimental because a variety of military hospitals do this procedure. I had a choice of the MTF or a civilian and they said they ould cover any of the 3 major WLS (lap-band, sleeve, and RNY). Good luck, I'm sire you will have to appeal and it will be a pain, but I have no doubt ey eventually will.

My hubby is retired and we have Tricare Standard, too, although Tricare is our primary insurance.   I was only able to have it done at a military hospital, not a private hospital.   I had mine done at Wilford Hall in San Antonio. 
It is my understanding that Tricare considers it experimental and won't cover it until after Medicare does.   
But, in any case, outside of a military hospital they have not covered VSG.

Until Medicare covers it, Tricare isn't going to pick it up with civilians. It's been like this for over 2 years now. I've gone back and forth, written congressmen, appeal letters, congressional complaints with military spouse friends and the only way it's an approved procedure is that if it is performed at a MTF that offers VSG.

You can attempt to appeal it, but for over 2 solids years, I can tell you that not one has been overturned or paid for by Tricare standard especially as a secondary insurance provider. Like I said, VSG and DS appeals and peer to peer reviews have gone all the way to IG and congressional complaints without resolution. When I checked in March, a new review of covered procedures will start this month with final determination will be determined 1 October 2011 when the new fiscal year budget is determined which is the same B.S. I've heard the same things since February of 2009.

The big difference is that Tricare does NOT typically pay for services at MTF, military clinics, those military surgeons make the same pay regardless of surgery type performed vs. hospital charges, and civilian surgeons. The dod system pays contractors and while Tricare has some fees with civi providers at military facilities, it's minimal. It's just not covered, and if by some grace of God you get it covered by Tricare Standard, please blog and document your story so others may benefit from it.

Definitely appeal!  I was denied for investigational status too, appealed it and won (the first my surgeon's office had seen with my insurance to win an VSG appeal).  My appeal letter has tons of research snippets and links to recent articles that you can print out and include with your letter as well.

You'll notice in my letter that I reference BCBS Federal covering the sleeve... in your case, I'd swap that out for Tricare Prime covering it, so it's rediculous that Standard doesn't.

Good luck!

Tricare does not cover vsg at all...as of yet. You can only have it done at the mtf. Military hospital funds and tricare are two different intities as they are funded differentyly by the government. VSG is currenlty under investiagation for coverage but they may take some time because more clinical data is needed. The only covered benefit is lap band and rny through tricare. But the mtf system has been cleared to perform procedures in controlled military hospital settings by military phycisians to collect the clinical and surgical information needed to present to the medical board to approve. So in short, vsg is an exclustion on tricare's policy there for not covered. You can file an appeal but it will not be over turned until vsg is a covered benefit under tricare. Oh, and I worked for Tricare/Trwiest for 3 years in Customer service and authorizations. hopes this helps. Good luck.