Help with requirements (Aetna)

[flmama 105]

These are the requirements by my insurance company (Aetna):

· Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) 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. Behavior modification program supervised by qualified professional; and
   
2. Consultation with a dietician or nutritionist; and
   
3. Documentation in the medical record of the member's participation in the multi-disciplinary 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 multi-disciplinary surgical preparatory regimen.); and
   
4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
   
5. Program must have a substantial face-to-face component (must not be entirely delivered remotely); and
   
6. Reduced-calorie diet program supervised by dietician or nutritionist.
   

So my questions are related to the bold items...

1. Is this counseling? And what is a qualified professional? Do they need to have a certain specialty or will any licensed professional do?

2. What is a qualified professional in relation to the exercise regimen?

3. Can I assume the dietician/nutritionist consult and the diet program with a dietician or nutritionist can be the same professional?

Or I could skip this and just do 6 months of a supervised diet/exercise regimen with my PCP.

[Momonanomo 534]

Have you chosen a surgeon yet? What I've done is put it all in the hands of my surgeon's office-- they have experience dealing with the insurance requirements (and interpreting them!)

Plus, your surgeons may have a specific "team"of all these specialists that they work with. I think most surgeons have a comprehensive program, and they will navigate you through all this.

best of luck!

[Lisa'slosinit 147]

same here !!!! pick your surgeons office and they should guide u in the right steps !!!i just had surgery thru aetna on dec 8 . here is what was required for me :

SIX CONSECUTIVE appts with a md...i used a nurse practioner ...and at every visit she had to fill out a form , which your wt loss ctr should give you

a mtg with a psychologist

meeting with a nutritionalist

attend a seminar

attend 1 support group

and you must attempt to lose 10 % of wt on your own !!!

once i got started on this , i didnt think 6 mos would ever get here .....but it flew by fast !! good luck !!

[nerlyc 15]

same here !!!! pick your surgeons office and they should guide u in the right steps !!!i just had surgery thru aetna on dec 8 . here is what was required for me :

SIX CONSECUTIVE appts with a md...i used a nurse practioner ...and at every visit she had to fill out a form ' date=' which your wt loss ctr should give you

a mtg with a psychologist

meeting with a nutritionalist

attend a seminar

attend 1 support group

and you must attempt to lose 10 % of wt on your own !!!

once i got started on this , i didnt think 6 mos would ever get here .....but it flew by fast !! good luck !![/quote']

I have Aetna as well. I have met all requirements described above. However!! I have not lost 10% or any weight at all. Do you think I will be denied? Due to the holidays my surgeon and staff have been in a holiday schedule and I haven't had a chance to talk to them. Anyhow, I'm calling tomorrow hoping they can begin the insurance process. Wish me luck ill be devastated if they deny me.

[ChristineR 128]

Our office offers a weight management program and so that counts as the behavior modification because a nutrionist leads it. I have to go to one class a month and have monthly weigh ins. The classes range from emotional eating to reading labels, etc. I also have to do a food log and exercise log weekly for her.

[flmama 105]

I don't have to lose 10% - I just have to fulfill the requirements of the program above by meeting multiple times over the 90 days with a psychologist for behavior mod, a NUT to learn how to eat better, and a personal trainer (certified) to increase pulmonary function and learn how to exercise for optimum post-surgery outcomes. And I have to see my surgeon 1x a month to oversee all of the areas and document them thoroughly (they all have forms to fill out and submit to him). I don't have to lose 10% though.

I'm sure every plan is different though. Mine is just the basically outline on Aetna's website without anything additional. And my surgeon doesn't require anything beyond what insurance does.

Thanks for all the responses - I was just hoping for some clarification prior to meeting with my surgeon's coordinator in a couple of weeks, but they felt sorry for me after I pestered them with calls and explained on the phone so I could start with the NUT, psych and PT now.

[ChristineR 128]

I met with the psychologist as well. I had to go in and take a 2 hour test (took me just over an hour) and then meet with him face to face. If it weren't for our patient coordinator I wouldn't even know where to start.