AETNA insurance 3 month multidisciplinary surgical preparatory regimen

Hi,  Have any of you done this?  I am wondering if I can do it somehow on my own.  The hospital I want to have surgery at is saying that I need to do some program call the LEAP that costs $1,000 but I think I could do this some other way.  I am looking for suggestions.  When I call Aetna all the say is to make sure that all of the requirements are there but it is kind of vague I think.  Who is considered a qualified professional?  Here is the policy bulletin.  Thanks!

1. 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:
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.)

7. and

8. 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, pre-operative psychological 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.

You can do this! I help patients do this at my office. You need a nutritionist consult before and after, and a PCP that is pro-WLS to do it. The nut needs to identify why you are there and at the end, summarize the changes you have made, and recommend proceeding with surgery. Your surg prep program must be 90 days, not 88, but 90 days long.  You need monthly documentation of your exercise and diet program with your doc. We use a check off sheet where the MD checks off the diet program, type of exercise done, etc and any behavioral modifications such as "patient is eating on a schedule, working to overcome emotional eating, etc" Then lists your vital signs, weight and BMI, and signs the bottom. You need one monthly documentation record for each of the 90days. Here is the kicker--at the end of the 90 day diet---your doc needs to type a separate letter saying the following: "Jaime has participated in a 90 day multidisciplinary  surgery prepatory program including a reduced calorie diet and exercise program and behavior modification techniques. At this point she has exhausted all non-surgical options for weight loss. She has increased her pulmonary reserve and lessened her operative risks for surgery. I recommend proceeding with bariatric surgery." See number 6 above in your criteria---the first month of your 90 days, your doc should include the assessment, something similar to: "Jaime is here to begin her multidisciplinary surgery prep program. SHe has been working on a 1200 calorie diet. She has begun walking 2 miles daily. SHe will be consulting with a dietician on 4/22/08. Jaime has identified several behaviors she would like to change, such as eating only once per day. She will receive more tips from the nutritionist, etc, etc, etc"  So--you get me??? You need both before and after notes from the MD and nutritionist as well as documentation each month of the program you are doing. If you do not have all of it, you will be denied. I learned the hard way about the MD after letter. Aetna would call me and ask for it, so I would have to scramble and get one before they denied it. We have also had denials for it being short of 90 days. You can use timeanddate.com to calculate days. You will get an approval from them in about 2 weeks after it is faxed in if everything is there. In addition to your lisitngs above, you must include one weight for each year---2006 and 2007 to prove you have been obese. You only need one copy of a MD office note that lists your weight, not 2 years worth of records. If your BMI is under 40, you need documentation of your comorbid conditions as well. If your BMI is above 40, you will only be submitting about 15 pages of documentation total. Your surgeons letter and office note asking for surgery, 2 office notes that have your weight and about 8 pages of your surgical prep program stuff. Make sure your doc and nut are on board and talk to them about this before, because if the documentation is not there, you will be denied. Good luck! It can be done! Bonnie

Hi Bonnie,  Thanks so much for the information!  I thought I could do it on my own but the hospital kept saying otherwise.  IS there any way you could get my a copy of the check off sheet you are talking about?  I have a fax machine at home or if you have a scanner you could email it to me.  My doctor is pro WLS but I don't think she has ever done this before and I want to make sure she does everything right.  Again thanks so much and if getting me a copy of that sheet is an option I can get you my info.  Thanks again, Jaime 

So let me get this straight: Meet with PCP Meet with nutritionist Do plan while meeting with nutritionist regularly (1x month ok??) Meet with PCP at end of 3 months for final weigh in and letter? Do I need to meet with PCP every month as well?

My PCP is clueless. He hasn't had a patient get WLS. He on the other hand is very supportive. He said he would do anything I needed him to do to get it approved. Needless to say I am not leaving my 3 month multi-dis in his hands so I am doing it with my surgeon's weight management center for a fee. I'd rather pay that and have it done right. So far he already messed up. I needed a referral for the surgeon (Aetna said so). He wrote it on a prescription pad. Surgeon's office said that would  not be acceptable. I told him I would also need a letter of medical necessity. He said just to type something up and he would sign it. Is this ok? Should it be on his letterhead or doesn't really matter. Also what things should I put in the letter. A lil about me. I'm 29, size 18, BMI 41, no co mormids. Not sure if there is alot to talk about in the letter. Any advice would be appreciated.

Sorry I forgot to do this...crazy busy....I am adding you to my schedule right now and will have it sent by tomorrow evening!

Thank you sooo much.  I really appreciate this.  I will let you know how it goes.  I have my doctors appointment tomorrow morning and I meet with the nut saturday morning.  Thanks again,