AETNA'S REQUIREMENTS

I went to Aetna's website and I'll be honest, its like jibberish. I dont understand exactly what they want. My surgeon's office gave me a copy of the requirements as well. No one can verbally tell me what Aetna's wants. Can someone please explain what exactly I would need to do for the 3 month disciplinary program and the 6 month diet? I feel like this is never going to happen for me if I dont get a handle on what I need to do.

I will personal message you on this one.

actually send me your email. it is lot for a personal message.

I will be glad to help you also.  I was approved by Aetna and had my surgery on March 9th.  I did the 3 month multidisciplinary program and was approved.  I read everything I could on here from people who had Aetna and made sure I did everything to the letter because if not, you will get denied. 

Basically there are 2 routes you can take...either the 3 month multidisciplinary program or the 6 month supervised program.  One thing I know for sure because an Aetna employee told me is they go by DAYS, not months, so your 3 month program really has to be 90 days and your 6 month program has to be 180 days.  If you try and submit and only have 88 days, for example, they will deny.

For the 3 month multidisciplinary program, you need to do the following:

a) See you PCP monthly....a total of four visits because the first one is the start of the program. Your PCP must document that you are there for weight loss and seeking surgery.  Make sure your PCP is documenting very well !

b) See a nutritionalist and/or dietician.  I saw mine monthly.  She sent her notes to my PCP's office who in turn documented in her notes that I was working with a dietician.
c) See an 'exercise specialist'.  I joined the gym at my place of employment and went to see the trainer who set me up on an exercise program.  I had him write a letter to my PCP, documenting that I was working out and had been set up on an exercise program.

c) Behavior modification - this is when you document things (must be in your PCP's monthly notes) of the behavior modifications you have talked about and working on.  Such things for me were:  joining an online support group (OH); joining a local support group, keeping a journal of what i was eating and how much I was exercising, not eating in front of the tv, etc.......  just make sure your PCP is documenting behavior modification in his notes.

Once the 90 days passed, it was all submitted to Aetna along with a letter from the Dr stating that surgery was a medical necessity.  They also wrote a letter stating that 'on this day, so and so started her 3 month multidisciplinary program' and another letter stating that 'on this day, sos and so completed her 3 month multidisciplinary program. 

if you would like copies of those letters, let me know and i can send them to you.  Feel free to PM me if you need more help.

Good luck to you!

 

 

I have been confused as well. I have Aetna HMO.

Today I called a hospital's diabetes education center (I think), they have a 12 week program where you see a dietician, an exercise therapist and a behavior ... whatever you call them.. 4 times each. Then I called Aetna to see if that might be covered, the very nice CSR I spoke with told me to see my PCP (which I need to see to start this whole thing anyway) and ask for a referral. This program costs $590 and the surgeon I want to use has a program that cost $250 but they're in another state. They will take payments but the first payment of $153 is due at the nutritionist evaluation (separate from the 12 weekly visits). By getting a referral, I'm hoping this means I don't have to pay out of pocket, my husband was recently diagnosed with Diabetes and he doesn't have to pay for his nutritional counseling and also got a blood glucose meter shipped free (the $80 one we almost bought in the store, it was prescribed by his PCP). This program is also group sessions, not individual.

The CSR tried to explain things to me over the phone but it's really confusing! She said there's a 5 year history that they need, even though the policy bulletin only mentions being diagnosed as morbidly obese for 2 years. She said she would be mailing me a copy of this info so hopefully I'll be able to get started gathering and completing everything really soon.

I have heard really promising things about getting approved by Aetna. I don't have records from 2008 or 2007 so my case may be a bit more challenging. I forgot to ask on the phone whether they'll take photos from 2008. I obviously wasn't any skinnier last year than I am this year

I did the 3 month regimen, as well, and it was pretty straight forward. I have a step by step list of what I did and copies of the letters I drafted and my PCP signed. I'd be glad to send these to you too. Just PM me with your email addy. :)

Hi.  I was glad to see that you had a good experience with Aetna!  I'm about to start the prpocess myself and would love to get a copy of the list and letters you used.  I'll PM you!!!  Thanks in advance.

Is there a time requirement on when you do the 3 month regiment?  Like a limitation?