Does TRICARE Cover Bariatric Surgery?

Tricare is the uninformed health care program for active-duty service members, active-duty family members, National Guard and Reserve members and their family members, retirees, retiree family members, survivors, and certain former spouses.

TRICARE recognizes bariatric surgery as an effective weight loss and overall health strategy for individuals who have been unsuccessful with other weight loss methods and covers several open or laparoscopic bariatric procedures.

Eligibility Requirements for Bariatric Surgery Through TRICARE

Even though bariatric surgery is generally covered through TRICARE, each individual requesting coverage must meet a list of qualifying conditions.

TRICARE eligibility requirements include the following:

• 18 years of age or older (or documentation of bone growth completion)
• Medical records indicating unsuccessful attempts at non-surgical medical treatments for obesity. Programs based on weight-loss medicine management only are not eligible.
• A body mass index (BMI) of 40 or greater or BMI of 35 or greater with at least one significant comorbidity, such as type 2 diabetes, cardiovascular disease, obstructive sleep apnea, and others

Bariatric surgery is not a decision to be made lightly, as it requires a lifetime commitment to a specific diet and weight management plan. Because of how this might impact active duty service members, TRICARE includes the following statement on its website:

“Bariatric surgery is a permanent change in your digestive system that requires following a specific diet plan that may interfere with operational deployment. Active duty service members who have bariatric surgery can’t re-enlist. Service members who receive bariatric surgery while on active duty may be separated.”

Bariatric Procedures Covered Through TRICARE

There are many different types of bariatric surgeries that all have the same goal of altering how the body handles food to aid in weight loss. TRICARE covers a wide range of open or laparoscopic bariatric procedures, including:

• Roux-en-Y Gastric Bypass
• Vertical Banded Gastroplasty
• Gastroplasty (stomach stapling)
• Adjustable Gastric Banding (LAP-BAND)
• Biliopancreatic Diversion with or without Duodenal Switch (for individuals with a BMI of 50 or more)
• Sleeve Gastrectomy
• Stand-alone laparoscopic sleeve gastrectomy

This list covers the most common types of bariatric surgeries, but there are also services and procedures that TRICARE specifically does not cover, including:

• Office visits solely for the treatment of obesity
• Non-surgical procedures for the treatment of obesity
• Nutrition and diet counseling
• Biliopancreatic bypass
• Gastric bubble or balloon
• Gastric wrapping/open gastric banding
• Unlisted procedures

Talk with your bariatric team about what type of procedure is best for you and how your individual TRICARE plan fits.

Potential Out-of-Pocket Costs for Bariatric Surgery Through TRICARE

Depending on your individual TRICARE plan and when the sponsor enlisted to the uniformed services, you may incur cost-share or copayment out-of-pocket costs associated with your bariatric surgery. TRICARE provides a Compare Cost Tool to help you determine what you can expect from your plan.

If you are still uncertain, contact TRICARE or ask for help from your bariatric center professionals. Your bariatric team is made up of compassionate healthcare professionals who have years of experience in communicating with insurance companies.

How to File a Medical Necessity Appeal With TRICARE

If your pre-authorization for bariatric surgery coverage is denied and you’ve already tried to call and resolve the issue by the simplest means possible, it may be time to file a medical necessity appeal with TRICARE. Medical necessity appeals can be expedited or non-expedited.

To file a medical necessity appeal:

• Send a letter postmarked within 90 days of the date on the explanation of benefits (EOB) or other decision to your contractor’s address.
• Include a copy of the EOB or other decision.
• Include any supporting documents. If you are waiting on additional documents, send the appeal without them and indicate that documents will be coming soon.
• Additional avenues include a request for a reconsideration decision and a request for an independent hearing. Steps for each of these can be found here.

The journey to better health is a worthwhile one but not one you have to take alone. Your bariatric center team of professionals is rooting for your success and is with you every step of the way.