Aetna help

[upurg 27]

I have been seeing my PCP since December 17th For weight management. He gave me a diet and exercise recommendation. My next visit was march 17. I was only down five pounds. I have been seeing him monthly since. Will this count as a diet plan or most I start over with a three month plan with the surgery center?

[alamergrl 8]

Here is what it says directly from Aetna's policy............

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:

   or

   1. 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. Records must document compliance with the program; the member must not have a net gain in weight during the program. 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; and
   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 (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)

2. 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. Records must document compliance with the program; the member must not have a net gain in weight during the program. (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.

Good luck!!!

[mchaviano 5]

Hi there. I have Aetna and am 6 days post op. Sounds like you may need to start from the beginning unless you have seen your physician on a monthly basis with weight documented, as well as a dietician and therapist. I used TMH Bariatric Center- wonderful group. I have a bariatric MD, dietician and therapist all in the same building. Once you complete the three month plan, and are not gaining any weight, the MD submits a letter of medical necessity and refers you to your surgeon. Once your surgeon gets the referral, they submit your paperwork to Aetna and from there is a waiting game. It was less than a week before I received my surgery date. You can call member services and they may be able to help you see where you stand. From start to finish, it took 5 1/2 months for the entire process. Good luck!

[upurg 27]

Thanks for the response. I have been seeing my PCP monthly but no dietitian. Well if I have to restart I will make the best of it. Thanks again.