Aetna PPO IL - 3 month or 6 month requirement

I had really thought that the group at U of Chicago would work with their patients to supervise the 3 month option, but apparently they "don't do that".  The options in blue or green below represent what is seemingly the most difficult to meet portion the the Aetna WLS qualifications.

6 month option requires cooperation of family physician/PCP but might be the only viable option at this point. 

Family docs have never been especially cooperative or understanding about weight loss anything, but I guess I can try again with my current doc.  6 months sounds like a long time, but if the precert really can go forward before the 6 months are finished it might not be so bad.

Maybe I can print out the requirement so doc will keep good notes.

If anyone has an idea or knows of a multidisciplinary pre-surgery program in Chicagoland please advise.

Thanks

Bill


14. 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:

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

16. 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

17. 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;

1. or

18. 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:

19. Consultation with a dietician or nutritionist; and
20. Reduced-calorie diet program supervised by dietician or nutritionist; and
21. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and

22. Behavior modification program supervised by qualified professional; and
23. 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.)

i have aetna as well, i did a six month program with my pcp but i didn't go every month so when i went ahead and enrolled myself in a barriatric program i found out it doesn't count as an actual six month diet because my progress wasn't recorded for six months. make sure you go around the same time every month!
My pcp didn't work with a weight loss dietician so I am currently doing the green option and seeing if it works. it is kind of expensive becuase aetna doesn't cover the dietician or behavioral modification. but the place im going is pretty reasonable as far as price goes, and its out of my surgeons office, so i get to see him the behaviorial health specialist and a dietician, its like one stop shopping.
  Honestly they make it seem a lot more difficult than it is. I go in around the same time every month for 3 months and the first time you go counts as a month! i just went to my october appointment and it took about an hour and i go again in november and after im done with my psych eval we submit!!
  My diet is rather restricted and much more difficult to follow than the one with my pcp but my dietician knows that i am doing this for wls so she is trying to get me used to eating foods i will have to eat when i get my wls.
  When i talked to an aetna rep. she told me they really want to see that you have tried to lose weight before considering wls, so have a record of every diet you've been on, and they also require a 5 year health history to make sure you didn't gain 100 pounds last year and want to do this to lose it.

I hope this helps a little bit. i know its long but it's my personal experience so far.

Hi, William! I am a DSer and had Aetna PPO also. Check out my profile for my experience. Long and Only Semi-Winding Insurance Road--Jan 4, 2008

I know that Northwestern has a multi-disciplinary program that easily cranks people through for their RNY surgical program--I did that for a few months until I discovered the DS. It was easy and straightforward and I was able to have all my doc, nut and psych appointments all in a row on a single day. That was great and the people there were super.

Don't know how it works if you are not using their surgeon, though. I ended up cobbling together my own team after they tried to talk me out of the DS (ultimately they said it was a good surgery but they didn't think I should have it because they didn't do it! At least they were honest! LOL)

It used to be called the Wellness Institute. I think this is the link:  http://nmpg.com/default.aspx?article=integrative-medicine.1. xml

Good luck!

And if you're looking for pre-op or post-op support, please feel free to come to our monthly DS support group meeting, on the third Monday of each month. It's mainly Dr. Rabkin's patients (he attends just about evey month), but we do have a couple of Alverdy/Prachand and one of Drr. Greenbaum's patients in our group. PM me for more info if you'd like. And please visit the DS forum--lots of good info there.

Nicolle