By Kristin Shives
TRICARE Management Activity
January 19, 2012
For those who have tried to lose weight but are still struggling to lose pounds by counting calories, eating a healthy diet and exercising regularly, surgery might be an option. Bariatric surgery is one option for the treatment of morbid obesity, but the surgery is not for everyone.
Bariatric surgeries change the digestive system, limiting a person’s food intake. Surgery can help in the weight loss process, and a lower weight can lower the risk of medical problems associated with obesity.
TRICARE covers bariatric surgery but it is limited and determined by certain patient criteria, one of which is a patient’s body mass index (BMI). A person’s BMI is a number calculated from their weight and height. This number is used to screen patients for weight categories that may lead to health problems including heart disease, type 2 diabetes, sleep apnea or hypertension.
TRICARE covers bariatric surgery for beneficiaries whose BMI is equal to or greater than 40 kilograms (kg) per meter squared, or who have a BMI equal to or greater than 35 per meter squared with a serious health problem linked to obesity. For example, a BMI of 40 is about 100 pounds overweight and equivalent to 295 pounds in a 6-foot person and 245 pounds in a 5-foot-6-inch person. The patient must have completed growth (be 18 years or have documented completed bone growth), and have documented evidence in their medical record that they’ve been unsuccessful using medical treatment for weight loss.
For beneficiaries who meet the medical criteria, TRICARE may cover the following open or laparoscopic surgical procedure:
•Roux-en-Y gastric bypass-The stomach is stapled to create a small pouch and a passage for food to go around a section of the small intestine
•Vertical banded gastroplasty or gastroplasty-Also known as “stomach stapling” the stomach is divided into upper and lower sections which limits space for food
•Adjustable gastric banding (LAP-BAND)-An inflatable band divides the stomach into two parts with the band wrapped around the upper part of the stomach. This allows for a small channel between the two pouches that restricts food intake.
Beneficiaries interested in bariatric surgery will go through extensive screening. Patients must be psychologically and medically ready for the surgical procedure. Health care providers will recommend changes in eating, drinking, exercising and stopping the use of tobacco.
Beneficiaries are limited to one bariatric surgery per lifetime, but there are certain conditions that allow for a repeat or revision for the covered surgery due to technical failure of the original procedure. All of the following must be met:
•The patient failed to lose at least 50 percent of excess body weight or reach body weight within 10 percent of ideal body weight at least two years following original surgery
•The patient met all the screenings criteria, including BMI requirements of the original procedure, and has been compliant with a prescribed nutrition and exercise program following the original surgery
•The requested procedure is a covered bariatric surgery
The success of weight-loss surgery depends on the patient’s commitment to follow guidelines about diet and exercise. Beneficiaries should speak with their health care provider to find out if bariatric surgery is an option for them.
For beneficiaries interested in learning their BMI, visit the Centers for Disease Control and Prevention’s website: www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.
For more information on TRICARE’s coverage of bariatric surgery, visit www.tricare.mil/coveredservices. To learn more on bariatric surgery for severe obesity, visit http://win.niddk.nih.gov/publications/gastric.htm.
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The TRICARE Management Activity administers the worldwide health care plan for 9.6 million eligible beneficiaries of the uniformed services, retirees and their families.