Aetna - 6 months diet vs 3 month multidisciplinary surgical prep

mystic_rhythm
on 5/6/06 2:02 pm - LANDING, NJ
Hi everyone, My husband and I are scheduled for WLS later in the summer and I'm losing my mind over the pre-op criterion for WLS approval. The aetna web site bulletin on WLS (http://www.aetna.com/cpb/data/CPBA0157.html) shows two options for WLS approval. The first is a six month physician-supervised diet. The second option is a three month surgical preparatory regimen requiring: 1. consultation with a dietician/nutritionist AND 2. reduced-calorie diet program supervised by nutritionist AND 3. exercise regimen supervised by exercise therapist AND 4. behavior modification program supervised by qualified professional AND 5. documentation of member's participation by a physician. The WLS center has never heard of the three month regimen and says it should be six months. I called Aetna (and got names) and asked for details about the three month regimen, and they said that all I need is a PCP doctor's note detailing everything that we are doing (which seems to be what the six month regimen requires). Has ANYONE gone through this three month regimen and what kind of documentation did you have to provide? We are prepared to do everything necessary. We met with a nutritionist and received diet information from her. Every month we go for a monthly weigh-in with our PCP (we're on month 2). We started an exercise program at home (who has money to pay another therapist??). And, we attend WLS patient support meetings every month. What else are we supposed to do? We are scheduled for surgery in July and August, respectively, and do not want to have an unpleasant surprise in mid-June when we try to wrap this up and go for insurance approval. Frankly, we're at a point that we'd like to keep the losses we've had so far and not start gaining back right before surgery...which is exactly what happens to us whenever we do any type of diet for more than 3-4 months. Any advice is greatly appreciated. Thanks! Anne
AJSkinnygrl
on 5/8/06 10:01 pm - Los Angeles, CA
Hi Anne, It has been almost 9 months since I contacted my Insurance Co. for Lap Band Surgery. It is such a pain the crap they make you go through. You are doing the right thing by documenting EVERYTHING!!! My insurance ****igna) told me pretty much the same thing that Aetna told you. They definitely advised me that they would NOT approve me unless I did a SIX MONTH regimen!! I have copies of my psych evaul, physical, Jenny Craig, and other diet documentation, plus 6 months with a Dietician and was STILL DENIED!!! I sought the advise of an atty and I am appealing. I have a Telephone Hearing with my atty and Cigna next week! They cannot make you do the regimen if you have the co-morbities, and are under a doctor's care! You have done what was required of you! Hang in there and don't let them stop you both from having surgery!! The bottom line is they don't want to pay and if they deny you they think you'll just go away!!!!!!!!!!!!!!! AJ
mystic_rhythm
on 5/9/06 5:22 am - LANDING, NJ
That is interesting...especially as we both have diagnosed co-morbidities (sleep apnea, we both have CPAP machines, and I have insulin resistance). I'm just losing my mind over this. Thanks for sharing your story...I really hope we won't have to fight this to the same degree! Anne
AJSkinnygrl
on 5/9/06 7:48 pm - Los Angeles, CA
Hi, The 2 of you may be O.K. You're right it's soooooo crazy Some are approved right away and others have to go through so much drama!! Keep in touch and let me know how things work out for you! AJ
Dreamy
on 5/11/06 9:57 pm
DS on 11/09/07 with
I'm just starting to look into wls and I have Aetna as well. From what I've been told, the 3-month thing isn't just for proving that you've tried to lose weight. It's more of a preparation for your body. The fatality rate for wls is still higher than many other surgeries, so it's to your benefit to lower your risks by having your body in as best condition possible. They want patients to build up their lung capacity with cardio to lower the risk of pulmonary embolism, for example, which accounts for many surgery problems. But I have to say, as much as I understand the reasoning behind it, I almost cried when I found out I would have to do this 3-month thing. I look at the before-and-after pictures on this site and I wish I had started this whole process years ago. I've even considered paying out-of-pocket just because I don't want to for 3-6 months When I read the policy I wondered why anyone would choose the 6 month option...since there isn't that much of a difference from the 3 month option??? Why would someone want to wait longer? I hope we're not misunderstanding the policy...although, it sounds like you got your info straight from Aetna....you'll have to keep us posted. I hope everything goes smoothly for you!
Jennifer Z.
on 5/22/06 7:12 am - Haslet, TX
Hi there -- I also am preparing for my surgery... I have Aetna as well. My Insurance Coordinator indicated that the Dr has to be CERTIFIED from Aetna to be the ADMINISTRATOR of the 3 month program --- ie it has to be the Surgeon performing the surgery. Otherwise any other dr. can perform the 6 month program. I changed surgeons prior to waiting to a surgeon that was able to do the 3 month program. I would say that your Surgeon is NOT on the Aetna 3 month list so I would either prepare to 1. Pay for it yourself. 2. Wait 6 months or 3. Find a 3 month surgeon to supervise. The good news - I just finished my 3 months - it goes fast. Plus I lost 16 lbs during the months without even really trying! And from what I understand once you complete, Aetna is ULTRA fast in approving. Good luck! JZ
mlynn1021
on 9/12/06 3:38 pm - Houston, TX

Hi Jennifer,  Today the doctor faxd my pre cert info for approval with Aetna PPO, Open Choice. I have sleep apnea, GERDS, High cholestrol and hypothyroid. I have the psych letter, nutritionist letter, history of dieting, medical records, cardiovasular tests, my own personal appeal for surgery. Will they still require the 3 month multidisciplinary thing? How do I find a doc in Houston TX? Thanks, M LYnn

mystic_rhythm
on 5/27/06 5:55 pm - LANDING, NJ
Well, here's my update: I've spoken to no fewer than six Aetna people about what this situation is. I've discovered that PCP documentation is NOT sufficient for this program; there has to be a combination of the following: 1. PCP or other physician-monitored weight loss program, 2. Diet supervised by a nutritionist with periodic reviews; 3. Counseling by a licensed counselor/psychologist with periodic reviews; 4. Exercise program with documentation by an outside party (gymnasium, trainer, etc.) The last portion of it is what really sticks in my craw at this point. My husband and I have participated in this program for two months and have had quite a bit of success; he lost 30 pounds, I lost 20. However, we have been exercising using our home equipment and not paying for a separate gym. Evidently this is insufficient; therefore, we have to pay yet someone else for yet another set of documentation. It turns out that our first surgery date was cancelled and therefore we do not need to get our stuff in until the end of July; we found a local fitness trainer to work with us for the next couple of months. He has agreed to review our last month's progress (as thankfully we did document what we did at home) and provide notes on it. That, plus two more months of monitoring gives us three months of exercise documentation and four months of everything else. I REALLY hope that this will be enough; according to Aetna and the surgery center, they are pretty quick with approvals once you get all of this documentation in. BTW, I did find out one piece of good news...Aetna PPO coverage for the bariatric surgery itself has a $150 co-pay, at least according to our insurance policy. We were very concerned that we would be liable for 20% of the hospital fee for the surgery, which would have been about $3k apiece. Thanks again to everyone for their input and their stories! Anne You might ask why we don't just stick out the six months; it's for professional scheduling reasons, if we don't get this done in early fall we'll have to wait until early next year. Otherwise we would have bailed on all of this and just waited it out.