Clinical Information Needed for Surgery Cases

Specialty providers should remember surgery performed exclusively for cosmetic reasons is seldom a TRICARE covered benefit.

Some procedures could be considered cosmetic, but may be approved if medically necessary. For example, breast reduction surgery requires the following information to determine medical necessity:

• Preoperative photographs, including anterior, side and shoulder views. Shoulder views should demonstrate shoulder grooving.
• Documentation of relevant symptoms, such as pain, paresthesia, skin breakdown, skin infections, and/or inability to participate in normal activities.
• Documentation of physical findings, such as hypertrophy, shoulder grooving, or intertrigo.
• Documentation from physician other than the surgeon requesting to perform the procedure regarding failed conservative therapy for the relevant symptoms, and work up to rule out other etiologies.

Specialists need to provide specific clinical information to TriWest before procedures can be authorized. There are clinical information forms and clinical program forms in the Forms section of www.triwest.com/provider.

For more information, please refer to www.triwest.com/provider or call 1-888-TRIWEST (874-9378).

Published Date: 01/15/2009