Is it Aetna or Drs Office Personel??

I am having a bit of trouble with my surgens office understanding the policy....if things are inblue i have done them, if not....I havent completed that.  tell me if i am not getting something,

 

 

Clinical Policy Bulletin:
Obesity Surgery
Number: 0157


Policy

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.

1. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:

   Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.

   Selection criteria:

   1. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following:

      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); or

         4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

      and

   2. Member has completed growth (18 years of age or documentation of completion of bone growth); and
   3. Member has attempted weight loss in the past without successful long-term weight reduction; and

   4. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

      1. 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:

         1. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
         2. 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

         3. 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

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

         5. 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.)

      and

   5. 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 (doesnt pertain to me!!), 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

   So here is what i dont understand.  I have 6 months of history, and i have 3 months in a row....but I dont have 6 months in a row and the lady that files the insurance says that i have to, but in this bulletin it doesnt say 6 consecutive months.

What else do I need to do in order to satisfy these people!!

 

I am almost in tears writing this!  Jeez!!

Have you shown this to the office personnel? I'm not sure why they won't submit you if you have clearly met the requirements as stated in the policy.

Who is your surgeon, and what surgery are you trying to submit for approval?

Dr Facundus in Huntsville Alabama, and Im trying to get RNY

Hmm...have you tried asking on the Alabama board about this surgeon's reputation? You may find others that have used him that can give advice or get recommendations on who to use instead.

By the way - his profile says he also does the DS. With your BMI, I would recommend that over RNY. Come to the DS board if you have questions about that, too. :)

Looks like you've done everything you need too, id say the person who submits is a moron.

Hello,
I work for a insurance company--who by the way approves gastric bypass.  For this procedure and any procedures many many many times that an insurance company denys a procedure it is becasue of shotty doctor documentation and office personell.   You would not believe how many chart documents we get that is completely illegible and when we call to get the information "translated" for us, it is usually an ordeal with the office personnel or the doctor screaming at use.    I would go to your doctor or doctors and ask to have your entire chart copied and then submit them to the insurance,  but check with your insurance carrier to make sure you can submit your own documents.  You may have to get copies of your chart from your pcp's and specalist and then take it to the Bariatric surgeons office and have them submit the paper work.  It is just about being proactive with your health care. 

Good luck.