Aetna supervised nutrition/exercise criteria???

[david6789 0]

1. 1. 
      
   2. Presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following:
      
   3. Body mass index (BMI)* exceeding 40; or
      
   4. BMI* greater than 35 in conjunction with any of the following severe co-morbidities:
      
      1. Coronary heart disease; or
         
      2. Type 2 diabetes mellitus; or
         
      3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea in Adults); or
         
      4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
         

      [*]and

      [*]Member has completed growth (18 years of age or documentation of completion of bone growth); and

      [*]Member has attempted weight loss in the past without successful long-term weight reduction; and

      [*]Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

      1. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:
         
      2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
         
      3. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and
         
      4. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;
         

      Above is Aetna's Criteria for Lap Band Surgery.

      Can anyone tell me the easiest/fastest way to meet the physician-supervised nutrition and exercise program or multidisciplinary surgical preparatory regimen?

      I want to bust out this requirement fast and get on to my surgery but of course I want to do it right so they will not turn me down.

      Some advise please.

   
   

[gatorgal 0]

Have you found a surgeon? If so, I would ask his/her office. The girl in my surgeon's office who handled insurance made sure I did EXACTLY what was required of my insurance plan, and because of her diligence in helping, I was approved within hours of her faxing the info to the insurance company. I did not have Aetna, but I was required to complete a 6-month pre-op program that included meetings with a nutritionist, 3-4 days a week in a gym (and I had to prove that I was going via a print out of all the times that I signed in to the gym), a meeting with a psychologist, and a pre-op education course regarding the band. It was intense, but again, I was approved within hours of her submitting my paperwork.

I will say that I'm glad I did the 6 months. It prepared me mentally for making the changes necessary to live with the band.

Sooooo, ask at your surgeon's office. Someone there will be able to guide you through the requirements.

[david6789 0]

I did speak to someone at the surgeons office and they have a program that will qualify. Unfortunately the only surgeon under my insurance plan is in LA with is 180 miles away. There is no way I can travel that far 3-4 times a week.

[gatorgal 0]

Surely they can connect you with dieticians and gyms in your area that will suffice?

[BgB9 9]

I had Aetna too. My surgeon has 2 dr's and a nutritionist in his office that do the supervised diet program. I did it, actually lost some weight but not enough. They submitted all the documentation and my approval was quick.

[BgB9 9]

I did speak to someone at the surgeons office and they have a program that will qualify. Unfortunately the only surgeon under my insurance plan is in LA with is 180 miles away. There is no way I can travel that far 3-4 times a week.

Call the dr and explain the distance. Ask them for more specifics about their program and if there is any online interaction or how many times you have to go in. I only had to go to my dr once a month for 6 months for the dr supervised diet and Aetna approved.

[BetsyB 9]

I don't have Aetna, but with my surgical group, "supervised" means returning to my surgeon's office monthly for a weigh-in. Their program is a non-program; those of us with insurance companies requiring 3 months' supervision were required to lose 6 pounds in that time frame, and those with a 6-month period had to lose 10 in 6 months.

The documented loss, combined with whatever magic they do in the office (with the questionnaires we fill out, their nutrition seminar) got approval nearly immediately after all the info was in the hands of the insurer.

Re: exercise--again, we were told to choose something and do it. What we did did not matter, as long as we progressively upped our activity. The doctor's documentation of our oral description sufficed.