Approval from Aetna finally

[JayTee562 1]

My insurance is switching to Aetna in January. Can someone give me an idea of what the three month diet plan is like?

Link to AETNA => Obesity Surgery

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:
   1. 
      
   2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; 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;
      

or

[*]Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three 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. 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.)
   

Edited October 14, 2008 by JayTee562
Pointed out link

[NanyC 0]

I have completed everything but the cardiac clearance. I can't get Aetna to approve it. They claim it's not necessary - I should say they won't pay for the chemical stress test and the doctor won't let me do a "regular" stress test. They said that it wasn't diagnostic. Has anyone else had this trouble. I am thinking that if I am having this much trouble getting this part approved - they are never going to approve the surgery... any suggestions???

[tmbowe 1]

candy3223.. why do you need to have a cardiac clearanceto get approval they way my Dr does it is you have to get approval for the bariatric surgery first. Then they will set up a pre operative appointment and they will handle all of those tests then.. because they are preop testing they are automatically covered so I am not sure why you would do the test before you even get approved for surgery

[vagabond 0]

I am glad to see that there are actually other people who are trying for the 3 month multi discipline to get approval from Aetna for the lap band surgery. I am due to end my 3 month run the first week in November and I am a little apprehensive about sending the paper work in. It is good to know others have done it and been approved.

[tmbowe 1]

OH My goodness I am so excited the Surgeons office called my Today and my Surgery is scheduled for December 5th.. I started this whole Process in January so I was beginning to think this day was never going to come. I am excited and nervous at the same time. For anyone out there who is having problems getting approved don't give up because it is worth the wait

[NanyC 0]

that's just how they do it. They gave me a list of steps that I had to complete before submitting to insurance - cardiac clearance, psych eval, nutritionist. The only thing I can't get passed is the cardio and they are calling this week. She told me if they wouldn't agree to pay for it that he would want to "cath" me - I dont think so. I think I will just have to do without the surgery.

[NanyC 0]

that's just how they do it. They gave me a list of steps that I had to complete before submitting to insurance - cardiac clearance, psych eval, nutritionist. The only thing I can't get passed is the cardio and they are calling this week. She told me if they wouldn't agree to pay for it that he would want to "cath" me - I dont think so. I think I will just have to do without the surgery.

[nancy104 0]

I have Aetna HMO and my surgeon submitted yesterday, Aetna called back and wants weight history for 2 years. My PCP has been my Dr for 5 years, every time I went to him I was weighed. Will that be enough proof for the insurence company? Even though my PCP wasn't treating me for weight loss?

[tmbowe 1]

as long as we can prove you have been overweight for 2 years that is all you need. I was pregnant in 2006 and sent them my weights from everytime I seend the obgyn that year and they accepted those. So as long as you have something from the Dr office showing your weight they will accept it.

[JayTee562 1]

I don't have HMO but was told by my coordinator said they just needed documentation that I've been over weight for the last two years. I asked if I needed documentation that I saw my PCP for the last six months for my weight she said no just documented that I was over weight 6 times and two years of records. I was suprised and will see in a couple month if that's correct.

[nancy104 0]

I was approved by Aetna HMO:thumbup:!! My surget date is Nov 10, I feel really Blessed, Aetna gave me no problems, I started this journey on June 19, 2008. Many Drs appts later it's finally coming to reality and definatly worth every minute sitting and waiting for Drs and lab work. Good Luck everyone:smile2:

[JayTee562 1]

I asked if I needed documentation that I saw my PCP for the last six months for my weight she said no just documented that I was over weight 6 times and two years of records. I was suprised and will see in a couple month if that's correct.

Well I was correct talked to my coordinator today and she needs 6 months of weight with my PCP. Of course I stupidly didn't make an appointment with him in October so I started with weigh-in 1 of my six months......... I should have used what everyone on here has said and made an appointment last month..I'd be two months closer.

All is really still up in the air because of our insurance change on 1/1 and we can't access the new company (United Healthcare) yet so I don't konw what they will want hopefully not much different than Aetna.

[floridachica 0]

I have a question for those of you that got approval from aetna hmo. My insurance is changing to aetna HMO as of January, but in the healthcare packet we received to enroll--there is a specific section that states bariatric surgery is NOT covered. Is this on everyones HMO? Or is it employer specific?

[nancy104 0]

floridachica, I actually called Aetna and spoke to someone and asked them if the band was covered. It is if your employer choses to include it.

[floridachica 0]

*sigh* unfortunately, they dont choose to include it. On either option availible. (there is also a BCBS PPO to choose if you like). Kind of surprising for a Fortune 100 company to specifically exclude it. I also spoke with the surgeons office yesterday. They said if it is specifically excluded there is not much they can do to get around it.

Im so dissapointed. Looks like i will have to wait a while longer and either start a new job that does have inclusion for WLS or look into self pay options. Neither is going to happen for a while. Im a stay at home mommy to my 2 small children and i work part time in the evenings right now. (The insurance is thru my hubby's company)