Anyone have AETNA.. Please look at policy??

Just wondering if anyone has Aetna and used the 3 month multidisciplinary regimen for approval. From what I understand this can be used instead of a 6 month medically supervised diet? Anyone use this?? Here is the policy... Any help would be GREAT>

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:

1.  
2. Consultation with a dietician or nutritionist; and
3. Reduced-calorie diet program supervised by dietician or nutritionist; and
4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
5. Behavior modification program supervised by qualified professional; and
6. 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.)

 

 

I have used it but here is what I found out in my denial.  The three months is not one visit a month for three months it is a total of 4 visits.  (I am working on my appeal right now) I did the following during all of that.

• Met with a nurse practitioner and talked about everything from diet to exercise to how to change my habits we met a total of 3 times (Needs to be 4 from what I can now tell)
• Met with a exercise consultant
• Had a stress test on my heart
•  Did a full psychological evaluation and talked to him about behavior modifications.
• Met with a dietitian twice went over everything

 

I can’t recall everything I did but this is the bulk of it.  There are two things I would recommend is work with a group that has done this and gotten people approved with their procedure.  Second see to it that from appointment 1 through appointment 4 that they have been evenly spaced and that there is 90 days total.

I had my surgery in April, 2006. I have Aetna HMO in Ohio. I started off prepared to do the 6 months PPC program Aetna askes for, but then after 3 months I tried to get them to approve me as the 3 months MDP. It worked. I had my appeal overturned and was able to have the surgery ASAP. When I submitted my papers I wrote a really good appeal letter. Had the pysch. eval Had the dietian info Had the physical therapy Had 10 years of doctors records and letters for all my doctors. What ever I did worked as they approved me for the 3 months. Good luck Shelly

Here is some new stuff from the insurance people at my surgery center:

 

Aetna is beginning to come back and request one additional visit for the Multidisciplinary Surg. Prep.Reg., stating that three visits do not add up to 90 days (3 months).

 

From talking to them if you have been denied due to this if you go back for one more visit they will overturn the denial.  So at this point I think it is more than likely the fastest way for me to get there.

The three month regimen is the only diet we use for our Aetna patients.  The process involves the following: 1) 3 monthly visits with a doctor for a supervised diet visit. 2) 3 monthly visits with a dietitian  3) exercise logs for 3 months---you do not need to join a gym. just jot down exercises on a calendar. Aetna also requires a 5 year history of obesity. Hope this helps! Tracy Burch Office Manager/Insurance Specialist Dr. Trace Curry's Office 513-559-1222 [email protected]

Thank you all for your information!!! I do have one other question for the AETNA experts out there ....I have been reading the policy over and over again and I cant figure out if there are specific requirements in order to get LAP band  covered.. opposed to bypass? I have read on other sites that Lap band is only approved for specific canidates. I would prefer LAP, but just wondering if its just more hoops to jump thru?? any ideas? Thanks again!!!

For Aetna, the requirements are the same for the band and bypass. Tracy Burch Office Manager/Insurance Coordinator Dr. Trace Curry's Office 513-559-1222 [email protected]