Question:
how can i get around the 6 month supervised diet?
my dr informed me that i met all the parameters for the wls except the 6 month supervised diet, how can i get around it i have aetna us health hmo — Richard A. (posted on April 10, 2003)
April 10, 2003
I hired Walter Lindstrom and he beat Aetna on the 6 mth Dr supervised diet!
By the time it all was done and said I was in mth 4 before I got approved!
My WLS is May 13! Applied to Aetna Oct. 2002, denied Nov, hire Walter Nov.
denied again Dec, and finally won at the external review in Feb. 2003! Good
Luck!
— CYNDI B.
April 10, 2003
If you go to your PCP tomorrow and get him/her to put you on a diet, you'll
have your 6 months supervised diet before you know it. I know people don't
want to do that, but the more people who have the surgery and the more
people who want it, the tighter the insurance guidelines are going to
become. 6 months is not all that long in the greater scheme of things.
Many people have to wait that long just to get in to see a surgeon. And,
yes, I had to have a much longer time of physician supervised weight loss
in order for my insurance to pay.
— garw
April 10, 2003
I've HEARD that if your insurance won't pay for what they are requiring,
like medically supervised diets or specific diets, that legally they can't
hold you to that. Not sure that helps but its something I remember being
told.
— Shelly S.
April 10, 2003
I don't understand why the first poster was denied in 2002 because the 6
month diet clause didn't go into effect until 1/1/03 (see 1/17 Aetna
bulletin).
I also have Aetna and have decided that by the time I would apply/get
denied/appeal/get attorney to fight....6 months will have passed and I
could just do the diet. That is what I'm doing now. I found a dietician
at my local YMCA who only charges $40.00 per hour. First vist was 1 hour,
all other visits have been 20-30 minutes. I'm not even submitting this to
Aetna, I just get copies of her paperwork. I go to my PCP every month for
a weigh-in as well as a follow-up on my recently diagnosed (6 months ago)
hypertension and pre-diabetic conditions. This gets the weigh-in's covered
by the insurance.
I would just do the diet and get it over with. It's much less frustrating
than trying to figure out how to get around it.
Good Luck.
— Carolyn M.
August 29, 2003
Aetna has changed the rules again!!!
Check this link for new information posted 8/22/03 for qualifying for
physician supervised weight loss management:
http://www.aetna.com/cpb/data/CPBA0157.html
Hope this helps everyone.
— aflower1
August 29, 2003
The requirements are now as follows:
Selection criteria:
1. Presence of morbid obesity that has persisted for at least 5 years,
defined as either:
1. Body mass index (BMI)* exceeding 40; or
2. BMI* greater than 35 in conjunction with any of the following
severe co-morbidities:
1. coronary heart disease; or
2. type 2 diabetes mellitus; or
3. clinically significant obstructive sleep apnea (i.e.,
patient meets the criteria for treatment of obstructive sleep apnea set
forth in Aetna CPB 004 - Obstructive Sleep Apnea: Diagnosis and Treatment);
or
4. medically refractory hypertension (blood pressure >
140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical
management); and
2. Patient has completed growth (18 years of age or documentation of
completion of bone growth); and
3. Patient has participated in a physician-supervised nutrition and
exercise program (including dietician consultation, low calorie diet,
increased physical activity, and behavioral modification), documented in
the medical record. This physician-supervised nutrition and exercise
program must meet all of the following criteria:
1. Participation in nutrition and exercise program must be
supervised and monitored by a physician working in cooperation with
dieticians and/or nutritionists; and
2. Participation in nutrition and exercise program(s) must be for
a cumulative total of 6 months or longer in duration, with participation in
one program of at least three consecutive months, prior to the date of
surgery. (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.);
3. Participation in nutrition and exercise program must occur
within the two years prior to 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 i) supervised the member's participation, and ii) does not
perform bariatric surgery. 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.
5. Pre-operative psychological evaluation and clearance is
required of members who have a history of severe psychiatric disturbance
(schizophrenia, borderline personality disorder, suicidal ideation, severe
depression) or who are currently under the care of a
psychologist/psychiatrist or who are on psychotropic medications in order
to exclude members who are unable to provide informed consent or who are
unable to comply with the pre- and postoperative regimen.
Note: The presence of exogenous depression due to obesity is not normally
considered a contraindication to obesity surgery.
* BMI is calculated by dividing the patient's weight (in kilograms) by
height (in meters) squared:
BMI = weight (kg) * [height (m)]2
Note: To convert pounds to kilograms, multiply pounds by 0.45. To convert
inches to meters, multiply inches by 0.0254.
OR
For a simple and rapid calculation of BMI, please click below and it will
take you to the Obesity Education Initiative.
*BMI = weight (kg) * [height (m)]2
— aflower1
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