Below you will find a list of medical/surgical services generally not covered under TRICARE or covered with significant limitations. This list is not intended to be all inclusive.
The following listed services are covered with significant limitations:
Abortions—Abortions are only covered when the life of the mother would be endangered if the fetus 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. MTFs may not be able to provide such services based upon limited capabilities (education, training, experience) of staff and facilities.
Botox® Injections—Excluded for cosmetic procedures, myofacial pain, fibromyalgia, and headaches. Limited in use for treatment of blepharospasm resulting in visual disturbance. May be covered in other circumstances, such as for the treatment of dystonias and muscle spasticity condition.
Note: Botox B (Myobloc®) is only indicated for treatment of cervical dystonia.
Breast Pumps—Heavy-duty, hospital-grade (E0604) 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, such as the inability to breastfeed. 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 (e.g., to facilitate a mother’s return to work), are excluded even if prescribed by a physician. Manual breast pumps (E0602) and basic (non-hospital grade) electric pumps (E0603) are also excluded.
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.
Chiropractic Care—Coverage is limited to ADSMs and is only available at specific MTFs under the Chiropractic Care Program. For more information, visit the
TRICARE Web site.
Clinical Preventive Examinations—A comprehensive clinical preventive exam is covered if it includes or is rendered at the same time as a covered immunization, Pap smear, mammogram, colon cancer screening, or prostate cancer screening. Clinical preventive exam claims usually include a general medical examination diagnosis (V70 or V70.0). School enrollment physicals for children ages 5–11 years are covered. Annual sports physicals are excluded.
Cosmetic, Plastic, or Reconstructive Surgery—Cosmetic, plastic, or reconstructive 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 for breast reconstruction after cancer surgery.
Cranial Orthotic Device or Molding Helmet—Cranial orthotic devices are listed on the No Government Pay Procedure Code List for all conditions.
Dental Anesthesia and Facility Charges—Medically necessary institutional and general anesthesia services may be covered to safeguard a patient’s life or in conjunction with non-covered or non-adjunctive dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or younger.
Dental Care and Dental X-Rays—Both are covered only for adjunctive dental care.
Diagnostic Genetic Testing—Diagnostic genetic testing is covered only when conducted to confirm a clinical diagnosis that is already suspected based on patient’s symptoms. Refer to the
TRICARE Policy Manual, Chapter 6, Section 3.1. For antepartum services, refer to the TRICARE Policy Manual, Chapter 4, Section 18.2.
Education and Training—Education and training are only covered under the TRICARE ECHO program and diabetic outpatient self-management training services. Diabetic outpatient self management training services must be performed by programs approved by the American Diabetes Association®, as evidenced by a Certificate of Recognition.
Eyeglasses or Contact Lenses—See “
Vision Care" earlier in this section.
Food, Food Substitutes or Supplements, or Vitamins Outside of a Hospital Setting—These are covered only for home enteral or parenteral nutrition therapy, such as when prescribed for cancer patients.
Gastric Bypass—Gastric bypass is covered for individuals who are 100 pounds (or more) over their ideal body weight with comorbidity, and for those who are 200 percent or more of their ideal body weight (in which case comorbidity is not required).
Note: Effective and retroactive to February 1, 2007, laparoscopic adjustable gastric banding (Lap-Band® surgery) is covered for eligible TRICARE beneficiaries. For more information on surgery for morbid obesity, refer to the
TRICARE Policy Manual.
For more information on Centers of Excellence for bariatric surgery, see “Referrals and Authorizations” in the
Health Care Management and Administration section of this handbook.
Genetic Testing—Genetic testing is only covered under certain conditions.
Hearing Aids—Hearing aids are covered for ADFMs who meet specific criteria. Hearing aids are not covered for retired service members, their families, or others. Implantable hearing aids are excluded.
Shoes, Shoe Inserts, Shoe Modifications, and Arch Supports—Shoes and shoe inserts are covered only in very limited circumstances. Orthopedic shoes may be covered when 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. For information on orthotics, refer to the
TRICARE Policy Manual, Chapter 8, Section 3.1.
