Aetna-Anyone have experience with Aetna Open Access
Our insurance is switching from Humana to Aetna in January. Sigh... I do not think I can get all my ducks in a row that fast. All the aetna stuff on here is very old, 1999-2000 messages. Does anyone have input on Aetna recently. We have Katy ISD coverage. Does "Open Access" coverage from Aetna cover WLS? I cannot find the info online anywhere as we are not currently customers of Aetna. If you are currently an Aetna customer can you look for me in the membership area online and see if Aetna and specifically Open Access level coverage covers wls.
Thank YOU!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Yea Righty Out..
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Home > Clinical Policy Bulletins > Medical > Obesity Surgery
Clinical Policy Bulletins
Number: 0157
(Updated)
Subject: Obesity Surgery
Reviewed: April 19, 2005
Important Note
This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. CMS's Coverage Issues Manual can be found on the following website: http://cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.
Note: Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. Please check benefit plan descriptions for details.
Policy
Roux-en-Y Gastric Bypass (RYGB):
Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB) medically necessary when the selection criteria listed below are met.
Selection criteria:
Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:
Body mass index (BMI)* exceeding 40; or
BMI* greater than 35 in conjunction with any of the following severe co-morbidities:
Coronary heart disease; or
Type 2 diabetes mellitus; or
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); or
Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
and
Member has completed growth (18 years of age or documentation of completion of bone growth); and
Member has attempted weight loss in the past without successful long-term weight reduction; and
Member must meet either criterion a (physician-supervised nutrition and exercise program) or criterion b (multidisciplinary surgical preparatory regimen):
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. This physician-supervised nutrition and exercise program must meet all of the following criteria:
Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
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
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:
Consultation with a dietician or nutritionist; and
Reduced-calorie diet program supervised by dietician or nutritionist; and
Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
Behavior modification program supervised by qualified professional; and
Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (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.)
and
For 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, a pre-operative psychological evaluation and clearance is necessary 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 depression due to obesity is not normally considered a contraindication to obesity surgery.
Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB or Lap-Band):
Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) or laparoscopic adjustable silicone gastric banding (LASGB, Lap-Band) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions:
Hepatic cirrhosis with elevated liver function tests; or
Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or
Radiation enteritis; or
Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).
Repeat Bariatric Surgery:
Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.
Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
Conversion to a RYGB may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.
Non-Covered Bariatric Surgical Procedures:
Aetna considers each of the following procedures experimental and investigational because the peer reviewed medical literature shows them to be either unsafe or inadequately studied:
Loop gastric bypass
Gastroplasty, more commonly known as "stomach stapling" (see below for clarification from vertical band gastroplasty)
Duodenal switch operation
Biliopancreatic bypass (Scopinaro procedure)
Mini gastric bypass
Silastic ring vertical gastric bypass (Fobi pouch)
Intragastric balloon
LASGB, except in limited cir****tances noted above
VBG, except in limited cir****tances noted above.
I have Aetna and the only thing I can tell you is, you have to meet and exceed what they ask for.
If you need any help please just let me know.
Sharon
Best thing to dois find a DR(surgeon in your area), look for one that does the 3 month pre-surgery regimen. I went thru it and was approved in 2 days...I have the QPOS option. You can always call your membership number and ask them if it is exluded from your policy.
At the end of my profile I have the link to the requirementsof both programs.
To pick a surgeon and checked here, and then went to Aetna's website, and cross referenced to see who was IN network...then I went to the ASBS website(Bariatric Surgeons), and checked to make sure they were a member in GOOD standing, then I took the numbers and started calling. When I first started calling MANY Dr's said I wouldn't find a DR who did that 3 month program, because it was new. WELL...I DID!!!!
I'm not sure where youlive,but my DR is fantastic, adn detailed..He had one the surgery, many times on people from different states even.
God Bless..
Any questions, feel free to contact me..
Tanya
349/385/**323**/185
I meant to add to my post that I also used Dr. Davis (Garth) and he sent me to an awesome PCP who did the 3 month multidiciplinary regimine with me. We submitted on Wed and had approval on Fri. If you would like his name just let me know. If you get started now you would be ready by the new year!
Huggs,
Sharon
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