Aetna - 3 mo Multidisciplinary pre-surgery regimen for approval

Hi everyone - I'm new to OH and have been reading thru some old posts regarding Aetna insurance.  I have Aetna PPO thru my work and they do cover WLS.  I have followed the Clinical Bulletin #0157 and trying to qualify for the 3 month vs 6 month plan. 

I started with my PCP on 9/29 and with my dietician on 10/13.  That would mean my 90 days would be up with my PCP on 12/29 and with my dietician on 1/11.   My surgeon's office sent in my request for approval too soon and I was denied last week, even though they knew I still had another appt with my Doctor.  Anyways, I was denied because I didn't have my 90 or 180 days in. 

Some of the older posts from this summer were stating that in order to qualify for the 90 day multidisciplinary pre-surgery regimen you needed to have two letters, one stating that you started the program and one stating that you have finished the program.  And that these letters needed to  be from your surgeon.  Also you need a letter from your physician too.  I meet all of the requirements (BMI of 47) and have the two year minimum obesity requirement.  I have been seeing my PCP and my dietician monthly along with attending WW. 

Has anyone been approved for the three month multidisciplinary program and been approved??    Tips for  being approved??

Thanks for any help you have.

Nan

Nan,

I can only tell you my experience and what I was told.  I had done the 6 months of WW, had letters from two differant PCP's regaring the medical necessities BMI, past failed Diet plans recoreded in my Drs reports, Dr reports for the last 5 or so years, psych evaluation, pulminary clearance and report, cardio clearance and report, Nutritionist reports and letter, support group letters of attendance, nutritional and behavioral seminars attended proof and it was all submitted to Aetna. 

Approx one week after submittal I received a denial letter stating that in all this paperwork and documentation there was no PHYSCIAN supervised EXERCISE program proof.  I called and discussed this with Aetna and they would not budge on this at all.  They told me all the paperwork submitted is above and beyond the requirements for approval EXCEPT not having the exercise documentation.

So back to the drawing board doing the three month plan with checking in with the PCP each month, nutritional seminars, support groups, joined the Y etc. 

I have now completed the three month regiment and am putting together all my appeal paperwork this week for submittal.  My fear now is during this three month regiment I injured my knee and have been in PT twice a week now and cannot do any kind of cardio etc exercise. 

So basically in short, make sure your documentation includes phycisian supervised exercise program and the could deny you as they did in my case. 

Best of luck to you and would be interested in how it comes out for you.

Wow - you had a lot of documentation!!  I am also worried about that.  I have no proof of my exercising, other than my telling my doctor my walking and working out.  She is documenting that in her notes. 

Keep me posted on your approval!  I hope it works out for you too!!  

I just read your post & wanted to let you know that I had the same situation as yours, but with Blue Cross/Blue Shield....my surgeon's office submitted paperwork too early & I was denied. My insurance requires a 6 month supervised nutrition and exercise program & so I have researched this in depth re: what is required. In fact, I called the Department of Insurance and asked them to verify certain policy requirements and to interpret what they mean. What I found was that if the insurance requires a 3 or 6 or 12 month nutrition and exercise program supervised by your PCP then your PCP is the be all end all to what is required.  For instance, my insurance states that I must see a Registered Dietition or Nutritionist for the six months and whatever she prescribes must be supervised by my PCP.  So, basically, WW would work for you (unless Aetna requires a NUT or RD) as long as you see your PCP monthly & have them "supervise" your plan.  Regarding the exercise portion of the six month requirement, my insurance does not specify that I have to join a gym, see a personal trainer or exercise physiologist, etc....all it requires is that my PCP supervise an exercise program for six months.  That could simply mean that I walk 10 minutes per day & do 3 sets of arm reps.  The insurance has deferred this to the PCP and they can't micromanage that.  As long as the time line is met with the supervision of the PCP then you have satisfied the requirement.

What you should look at is the time line that you have after your denial to submit your appeal.  Clearly,  you have a ton of paperwork that you have submitted & it sounds like they have cleared you on everything, but the supervised exercise....so, does your insurance give you at least 90 days to file an appeal to the denial?  If so, then you can go to your PCP for the next three months & get the supervised exercise documentation & then submit it with your appeal paperwork under the umbrella of the appeal.  That way, you are not starting from scratch & they cannot come back & say that you failed to meet another requirement. 

I started my 6 months supervised in September 2008 & have been in Oct/Nov/Dec & will go in Jan & then my last appt will be in Feb.  Since my insurance comany give me 180 days (6 months!) to submit additional documentation for the appeal (I was denied in October) I have until April 2009 to get the rest of my paperwork in.  They have already conceded that I have everything but the 6 month supervised nutrition & exercise program, so I will submit the additional paperwork in February &, hopefully, be approved.  I feel pretty good about my chances & my PCP is behind me 100%, so we should be able to get this done &, hopefully, I will have a surgery date by the end of March!!!

Either way....this is going to be one heck of a 2009 for all of us who are going to have surgery!!! Good luck! 

I'm two months into the Aetna three month regimen.  My surgeon's office has a component that does the supervised diet where I meet with a weight loss doctor (not the surgeon), nutritionist and exercise therapist. I have to meet with the dr monthly, the nutritionist about every 6 weeks, but I've only met with the exercise therapist once.  I journal my exercise but I didn't join a gym and the dr and I discuss how I'm doing on exercise at our monthly appointments.
I haven't been approved yet but they tell me that it is very rare for them to be denied so I'm just trusting that they've done this enough to know what they are doing.

Get your PT to write a letter saying that you have been seeing her and get her to detail everything you have been doing. This should be enough. Does your PT give you excersizes to do? Mine does. She wrote a letter stating that Im having treatments and the excersizes that she is giving me. I sent this in and they did not have any problems with it. I was denied because I want the sleeve and they say it is experimental. Im appealing it. I have Aetna PPO. Skye

I joined the Y for the simple fact it clearly states in Aetna's requirements:
 

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:........

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 .........

My PCP is not a exercise therapist and I interpreted "qualified professional" as someone who works in that type of field.  I may be wrong but after already being denied because my first PCP who I was seeing during the WW program did not make mention of the exercise we discussed numerous times and in fact developed a stress fracture in my foot during walking exercise I wanted to make sure I was hopefully covering all bases.

Nan,

You're not alone in your Aetna induced frenzy!

I'm still working on the Aetna 3 or 6 month option too and I know there are others.  My first appt was 10-31-08, so if all goes well I'll be compiling a packet and sending to surgeon after my January PCP & dietician appts.

I've heard from successful Aetna patients that the 3 consecutive calendar months with detailed notes in charts completed by PCP, dietician or nut, and then documentation of an exercise/fitness plan with a letter explaining was enough to meet the 3 or 6 month requirement.

I've been lurking on OH for quite a while, and each successful Aetna patient I've heard from or about had to organize their own regimen or program with cooperation from their doctors.

p.s  It took me YEARS to find a PCP who was not completely opposed to WLS

Good Luck in your quest for approval!

William,

Thank you for the reply.  I appreciate all the encouragement and honestly reading these posts keeps my hopes up high that I will be approved.  I can not have the surgery unless my insurance pays for it .  The waiting is the hardest part!! 

I am seeing my PCP and dietician on the 12th (11 more days!) for my final appointment.  That will complete my 90 days.  I plan on submitting a letter that I write on behalf of myself, getting a letter from the trainer that set me up with an exercise program, a letter from the dieticien.  Then I plan on having my doctor wirtie the summary letter stating when I started and when I completed the 3 mo multidisciplinary program. 

I'm glad for you that you found a PCP who supports WLS.  Mine has been very supportive and told me 'whatever you need me to do to help you get this approved, just let me know" . 

Good Luck to you too, and let me know when you're approved!  

Nan

 

 

 

I have aetna, and i did the three month pre op.  i sent my paperwork in got approved within 10 days.

 

if you like i can pass along the info that was given to me.  I actually went to my dr every 30 days or so....i joined a gym, had an employee do an assesment and set me up with a workout plan...i followed that , i did a calorie reduction, and made a letter with the notes from each visit...as my "support group" i used obesityhelp as my support in my letters, if you like i will email them to you...i was approved rather quickly.  this was my last step.

 

i got my approval letter from aetna yesterday, and i am scheduled for surgery on Feb. 2.