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Services or Procedures with Significant Limitations


View a list of medical, surgical, and behavioral health care services that may not be covered unless exceptional circumstances exist. This list is not intended to be all-inclusive.

Figure 4.9 Services or Procedures with Significant Limitations



 Service Description
Abortions Abortions are only covered when the life of the mother would be endangered if the pregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a life-threatening condition existed. Medical documentation must be provided. 
Breast Pumps Heavy-duty, hospital-grade electric breast pumps (including services and supplies related to the use of the pump) for mothers of premature infants are covered. An electric breast pump is covered while the premature infant remains hospitalized during the immediate postpartum period. Hospital-grade electric breast pumps may also be covered after the premature infant is discharged from the hospital with a physician-documented medical reason. This documentation is also required for premature infants delivered in non-hospital settings. Breast pumps of any type, when used for reasons of personal convenience, are excluded even if prescribed by a physician.
Cardiac and Pulmonary Rehabilitation Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded.
Cosmetic, Plastic, or Reconstructive Surgery Surgery is only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement after cancer surgery, or reconstruct the breast after cancer surgery.
Cranial Orthotic Device or Molding Helmet Cranial orthotic devices are excluded for treatment of nonsynostotic positional plagiocephaly.
Dental Care and Dental X-rays Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition).
Education and Training Education and training are only covered under the TRICARE Extended Care Health Option (ECHO) and diabetic outpatient self-management training services. Diabetic outpatient self-management training services must be performed by programs approved by the American Diabetes Association®. The provider’s “Certificate of Recognition” from the American Diabetes Association must accompany the claim for reimbursement.
Eyeglasses or
Contact Lenses		 Active duty service members (ADSMs) may receive eyeglasses at an MTF at no  cost. For all other beneficiaries, the following are covered:
  • Contact lenses and/or eyeglasses for treatment of infantile glaucoma
  • Corneal or scleral lenses for treatment of keratoconus
  • Scleral lenses to retain moisture when normal tearing is not present or is inadequate
  • Corneal or scleral lenses to reduce corneal irregularities other than astigmatism
  • Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from intraocular surgery, ocular injury, or congenital absence
    Note: Adjustments, cleaning, and repairs for eyeglasses are not covered.
Facility Charges for Non-Adjunctive Dental Services Hospital and anesthesia charges related to routine dental care for children under age 5, or those with disabilities, may be covered in addition to dental care related to some medical conditions.
Food, Food Substitutes and Supplements, or Vitamins Food, food substitutes and supplements, or vitamins are covered when used as  the primary source of nutrition for enteral, parenteral, or oral nutritional therapy. Intraperitoneal nutrition therapy is covered for malnutrition as a result of end-stage renal disease.
Gastric Bypass
Gastric bypass, gastric stapling, gastroplasty, or laparoscopic adjustable gastric banding (LapBand® surgery)—to include vertical banded gastroplasty—is covered when one of the following conditions is met:
  • The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders, and severe arthritis of the weight-bearing joints.
     
  • The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
     
  • The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).
Genetic Testing Testing is covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient. Routine genetic testing is not covered.
Hearing Aids Hearing aids are covered only for active duty family members (ADFMs) who meet specific hearing loss requirements.
Intelligence Testing Testing is covered only when medically necessary for the diagnosis or treatment planning of covered psychiatric disorders.
Laser/LASIK/Refractive Corneal Surgery Surgery is covered only to relieve astigmatism following a corneal transplant.
Private Hospital Rooms Private rooms are not covered unless ordered for medical reasons or because a semi-private room is not available. Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment system may provide the patient with a private room but will receive only the standard DRG amount. The hospital may bill the patient for the extra charges if the patient requests a private room.
Shoes, Shoe Inserts, Shoe Modifications, and Arch Supports Shoe and shoe inserts are covered only in very limited circumstances. Orthopedic shoes may be covered if they are a permanent part of a brace. For individuals with diabetes, extra-depth shoes with inserts or custom-molded shoes with inserts may be covered.

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Last Reviewed: July 06, 2010