Has anyone here used TriCare Prime for DaVinci?

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HD_Rider
Regular Member


Date Joined Apr 2011
Total Posts : 414
   Posted 5/7/2011 7:06 AM (GMT -6)   
Has anyone here used TriCare Prime for DaVinci?   According to what I can find, TriCare Prime will not pay for DaVinci and will only pay for the open method of surgery.

Does anyone have any specific experience with TriCare Prime?

Susan R
Veteran Member


Date Joined Dec 2010
Total Posts : 511
   Posted 5/7/2011 7:54 AM (GMT -6)   
HI, we just went through this. As long as the URO or your PCM requests the Da Vinci they will approve it and pay for all of it. We havent had to pay even 1 penny for the procedure. YOu can pretty much get anything from Tricare as long as the requesting DR is extremely specific about what they are asking for. Let me know if you have further questions. Tricare has also just approved my hubby to get 90 pills per 90 day period of 20 mg levitra. So they as open to doing what the dr asks.
Husband 39 at diagnosis 12/2010.
No symptoms, PSA 18 in 10/2010
one month antibiotic then PSA 12.6 in 11/2010
biopsy end of 11/2010 Gleason 6
Da Vinci prostatectomy 2/2/2011
1-2 pads per day
nocturnal erections within a month, and able to have sex with Levitra.
1st post-op PSA less than .05

staging: pT2aNo, Gleason 6

HD_Rider
Regular Member


Date Joined Apr 2011
Total Posts : 414
   Posted 5/7/2011 8:19 AM (GMT -6)   
Susan - Thanks for responding and I so desperately need your help.
 
I am working with a urologist in my area who is very experienced in the DaVinci method.  I spoke with the doctor's nurse on Thursday who is setting up the surgury and submitted it to Tricare Prime.  Today, I checked my Tricare account on line and found that the "robotic surgical system" was dissapproved with a reason of "Not a Tricare Benefit".  According to the dissapproval letter, it states "The requested procedure is not recognized by Tricare and cannot be used for a benefit decision.  If the requested service is provided, you will be held financially responsible for all related charges."  That almost sounds to me like the person reviewing the request from my doctor did not understand what was meant by "robotic surgical system" and without knowing what it was simply dissapproved it.
 
Do you know off-hand what procedure(s) were specifically requested by your doctor?  I'm hoping my doctor simply submitted the request wrong, but I am now so stressed-out and scared and just don't know what to think.
 
I would sincerely appreciate any additional info you might be able to provide.  If you want, you can e-mail me directly at **Removed by site staff **  Thanks so much.
 
 
 

Post Edited By Moderator (Steve n Dallas) : 5/7/2011 8:32:41 AM (GMT-6)


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4829
   Posted 5/7/2011 8:34 AM (GMT -6)   
HD_Rider - I removed the address you posted so you won't get spammed to death from the bots that will harvest your address... You can add it to you user profile so others can email you.
 
Call Your surgeons office and let them deal with it. Odds are they will be successfull according to what Susan posted.

Susan R
Veteran Member


Date Joined Dec 2010
Total Posts : 511
   Posted 5/7/2011 8:34 AM (GMT -6)   
sent you an email
Husband 39 at diagnosis 12/2010.
No symptoms, PSA 18 in 10/2010
one month antibiotic then PSA 12.6 in 11/2010
biopsy end of 11/2010 Gleason 6
Da Vinci prostatectomy 2/2/2011
1-2 pads per day
nocturnal erections within a month, and able to have sex with Levitra.
1st post-op PSA less than .05

staging: pT2aNo, Gleason 6

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 5/7/2011 12:48 PM (GMT -6)   
Rider,
I checked into this two years ago and Tricare would not approve Robotic. They did approve laprascopic. I was told that I would have to pay the difference between laprascopic and robotic. I hope Susan is correct and you can talk someone into approving it.
JohnT
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 2 years of psa's all at 0.1.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3747
   Posted 5/7/2011 5:27 PM (GMT -6)   
Today, around 90% of the prostate surgeries are done roboticly. It has become the standard of treatment. Maybe not yet in the VA hospitals...When I was investigating my surgery, the surgeon told me Medicare paid the same amount for either procedure, open or robotic..A Prostatectomy was a flat-rate deal more or less.

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 5/8/2011 7:19 AM (GMT -6)   
For what it's worth, I had DaVinci with Medicare as primary and Tricare For Life as secondary, and it was all covered. I think Tricare as secondary pretty much follows whatever Medicare does. But I don't know if they would have covered DaVinci if they were primary, whether Prime or Standard.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05
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