Bariatric (Weight Loss) Surgery
Gastric bypass, gastroplasty (stomach stapling), vertical banded gastroplasty, adjustable gastric banding, biliopancreatic diversion*, sleeve gastrectomy and stand-alone laparoscopic sleeve gastrectomy may be covered benefits when the following conditions are met:
- Beneficiary must be age 18 and older or have documentation of completed bone growth,
- Medical record documentation indicating previous attempts for non-surgical treatment of obesity were unsuccessful and
- Body mass index (BMI) is greater than or equal to 40 kg/m2* or
- BMI is 35-39.9 kg/m2 and the beneficiary has been diagnosed and is currently undergoing treatment with one of the following comorbidities: cardiovascular disease, type 2 diabetes mellitus, obstructive sleep apnea, Pickwickian syndrome, hypertension, coronary artery disease, obesity-related cardiomyopathy or pulmonary hypertension.
*A biliopancreatic diversion (with or without duodenal switch) may be covered for individuals with a BMI greater than or equal to 50kg/m2.
A pre-operative psychological evaluation and psychological testing, are covered benefits as part of the initial assessment to determine if the individual meets the requirements for surgery.
There is a once per lifetime limit on weight loss surgery cost-shared under TRICARE.
Prior Authorization Requirements
- TRICARE Prime beneficiaries require prior authorization for all weight loss procedures.
- For TRICARE Select beneficiaries, we recommend providers submit a request for prior authorization to determine if TRICARE requirements are met.
Revisions for bariatric surgery require medical necessity review; providers should submit a request for prior authorization to determine if TRICARE requirements are met.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Services Not Covered
- Office visits solely for the treatment of obesity
- Non-surgical procedures for treatment of obesity
- Nutrition and diet counseling
- Gastric bubble or balloon
- Gastric wrapping/open gastric banding
- Unlisted procedures
(This list is not all inclusive.)