Post Date: 12/27/08 5:21 am
Good Morning KMills,

I work for Aetna and am in the process of going through the 3 month supervised diet and registered dietician that we require. First, let me preface this by saying you definitely need to contact Aetna. They will refer you to a specific rule for your plan. However, please ask them if there is a clinical policy bulletin. They will give you the # to type into your Aetna homepage. It will give you very specific requirements. I can safely say I've never heard of anyone that has had to meet that requirement as of yet. This may be a requirement for your surgeon tho? 

I do know two things I have learned so early into this:
1) Your appts. have to be between 31-35 days apart to count. Any sooner is out of the question.
2)Even working for the carrier, their information sometimes becomes very vague and bland when speaking with a person there. I always rely on the print outs that I get from the person and also write their names down. I've witnessed 3 friends I know go for 3 different WLS procedures. ALL were approved within a week. Their secret, I will definitely use.  When you submit for approval......call them. EVERY DAY! Call, ask if they received it.....call ask if they reviewed it.....call calll call....kinda like after surgery with the walk walk walk and sip sip sip. I've never seen them turn anyone down in my unit yet.

When I worked for Blue Cross, their requirements were very stringent and they would deny over 88% of the time. However, they were good about approving the appeals.

Anyhow, sorry, didn't mean to go on. I hope this helps. The Clinical Policy Bulletin in question should be numbered as 0157 and you can do all of this online. I just went and checked as well again.

Take Care and Good Luck,

Missy

Post Date: 12/27/08 8:26 am
Hi Nan,

As long as you have done this for a continuous  90 days, with a total of 4 visits beginning to the end, spaced 31-35 days apart, there should be no problem. I can't get to see my dietician and MD at the same time. They are spaced a week apart each month. But, I intend to do a total of 4 appointments with each before my submission. Am going to have my psyche clearance done the 19th of January so that it can be submitted too.  Have you been involved for a total of 90 days with the dietician and the MD? If so, and as long as they are spaced apart, you should be fine!

Let me know how it goes. I'll keep my fingers crossed for you!

Take Care,
Missy

Post Date: 12/27/08 8:58 am
That's AWESOME !!!!

I'll keep my fingers and toes crossed for you Nan. Once they submit, give it about 2 days and then begin the calls. Every day, more if you feel the need.  Stay in touch and please don't hesitate to call me at the office if there is something I can do. I am actually a Small Group account manager, but I can find the powers that be if you need it. I'm thinking you did everything by the book and will come out of this just perfect!

Good Luck and God Bless,

Missy

Post Date: 12/27/08 12:32 pm
I was approved w/ Aetna with just 6 months of weigh ins and "diet and exercize councelling" w/ my pcp. I did not have to go to an exercize physiologist or even show proof of gym attendance. I'm not sure if different policies have different criteria though b/c I just heard of a 3 month weigh in policy.

Post Date: 12/27/08 3:39 pm
 another Missy here.... I just got approved through Aetna but did not hear one word "boo" about an exercise physiologist.  my appointments were also not necessarily 31-35 days apart.  

again, it depends on your specific policy... but... with that being said.  i did the 3 month thingy and lost about 20 pounds in 3 months.  I don't know if that influenced it or not.


mis. 

Post Date: 12/30/08 6:08 am
I have a question???? When it says three months do they count the days? Are they looking for 90 days because if they are my doctor has it all wrong..... They told me that I have completed the 3 months with my appointment days falling on Sept. 29, Oct. 31., and Nov. 26. My doctor said that is considered three consecutive months, but if you count the days it is only 54 days. I am so confused on how this all works. I have been denied once before because they said that I hadn't completed the right amount of time. Aetna said that I only did 2 1/2 months and they denied my request. I am trying to get in touch with the doctors office to see if I need to do one more appointment but no one is available. I have been trying to get this all done since Jan. 2008, and beginning to get very frustrated because I can't get a straight answer. Please help me and tell me a correct answer!!! Thanks!!!

Post Date: 12/30/08 12:42 pm
I am so confused!!! my doctors office swears that they are correct, but after talking with patients on here I think that they are wrong. I' ve been calling Aetna all day and can't get a straight answer out of them. Actually, I am on hold right now... I have been denied before because they said that I didn't complete enough time, so I am very nervous about what the outcome will be. I called my doctor and was told that they already sent off all the paper work this morning... So all I can do now is sit and wait!!!