Please Help interpreting the Aetna EPO requirements.

[bonitachica9679 0]

So I just went to my lap band consult appt last Thursday and they said I qualify. I'm much too impatient to do the 6-month option Aetna has so I want to go with the 3 month one (requirements pasted below). My surgeon's office has something in place for the 6 month route but they can't tell me anything about the fast track one and what I should do. I tried finding a different doc in my area that might but no such luck. If anyone using Aetna EPO has been approved for lap band using the 3 month option, PLEASE tell me how you did it. Mainly the exercise regimen (Excluding a personal trainer as that is too expensive)

Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multidisciplinary surgical preparatory regimen of at least three consecutive months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:

1.

Consultation with a dietician or nutritionist; and

2.

Reduced-calorie diet program supervised by dietician or nutritionist; and

3.

Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and

4.

Behavior modification program supervised by qualified professional; and

5.

Program must have a substantial face-to-face component (must not be entirely delivered remotely); and

6.

Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial

assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)

[krekre28 0]

I am currently going thru the 3 month process. All I have to do is see a nutritionist for 3 months, she set up my exercise, diet and behavior modification program. I am hoping to be banded in August. My WL surgeon referred me to her, apparently she knows exactly what Aetna needs and is able to give them all the documentation they need. I see her every two weeks. I hope that helped, maybe ask if they can give you a name of a nutritionist in your area or call Aetna yourself and ask them.

Evonne

[bonitachica9679 0]

Hi krekre28

Is Aetna paying for the nutritionist visits? I was actually able to find a exercise physiologist to cover the the exercise requirement and it only costs $100 for 3 months so that worked well. I'm now having trouble figuring out the nutritionist requirement. My surgeon's office recommended one, but if insurance doesn't pay it will cost $90 for every 30 minute session. Do you know how may sessions Aetna requires you to do within the 3 months? Thanks for the info :thumbup:

[krekre28 0]

I do not have to pay anything out of pocket for the nutritionist, I called Aetna to make sure, after the doctor referred me. I do not even have to pay a co-pay. The doctor and nutritionist told me that I will see her for 3 months, it did not matter how many visits within that 3 months, so I could see her once a month if I wanted. But I really want to learn from her as much as I can so we decided to schedule every two weeks. My doctor told me that there are several different Aenta plans, and I lucked out having one that my doctor contracts with, so I would really suggest calling Aetna Monday morning and finding out more information on the qualification part. Ask if they can suggest someone that qualify's to do all the components of the qualification process?

This insurance stuff stinks, the waiting process seems like forever. Let me know how things go and if there is anything I can help you with. We are in this together:smile2:.

Evonne