GOING THROUGH PROCESS WITH AETNA CHOICE POS II

Hello All-

My name is Maria, I am 37, married with a 13 yo step daughter. I am at about 350, with a BMI of around 60.  I am currently going through the process with getting the WLS surgery, and hoping my husband will too.

I am gathering all of my medical records to prove all the neccessary info, I have two medically supervised weight loss programs one for 3 mos in June, July and August of 08 and one in Jan-June 2009, so I am hoping they take those...

I am scheduling with the PSYCH person...

But heres my question:  If they dont take those things, can I make my own 3 month program by going to my physician, a sports medicine person, and a psychologist once a month?  Also, what kind of certifications would the exercise person have to be?

Thanks for any info, would love to chat with anyone in the early stages as well!  :)

Maria

 Hi Maria,

I was approved by Aetna about a year ago after completing their 3 month Multi-Disciplinary program.  I don't mean to discourage you, but the programs you participated in from 2008 and 2009 will more than likely not work towards your approval.  The wording in the clinical bulletin is something like  'proximate to surgery' which means right before surgury.  They are looking for one of two things (you can read this by going to Aetna's website and searching on clinical bulletin 0157).  They require either a 6 month physician supervised diet or a 3 month multi disciplinary program.  I did the 3 mo MD program.  I needed to go to my physician (4 visits), a dietician (4 visits), an exercise specialists.  Each the doctor and the dietician documented my exercise, reduced calorie diet and behavior modification in their physician notes.  The 3 months must span over 90 days or the 6 months over 180 days.  Make sure your doctor is documenting all of this in their office visit notes.  Especially the behavior modification.

If you want more information I'll be glad to help you answer any of your questions!

Thanks for the response- I appreciate it !  : )  I thought the same thing, but I think the wording might have changed, because its different since the first time I applied....  Its tough, even just gathering the medical records, but I am doing it, one way or another, I will get the pre-work done.  No where that I know of has the official three month program, but I could see my primary care and a psychologist... any ideas on where I get an exercise psys person?

I have copied the section below, see where its confusing?  Check out #2?  Thanks for your support!

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, with a substantial face-to-face component (must not be entirely remote); 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;

Hi, Maria. I'm Rosie. I had RNY 9-16-08 and also had Aetna POS II. There was not an official 3 month program available to me, so I did create my own. I have a checklist of what I did, as well as letters that I drafted and had my PCP sign. I'll be glad to send them to you if you'll PM me your email address.

I am switching from BC/BS to Atena POS II effective Sept 1.  I would really like to have the lap band, but I can not pay for it out right.  It is my understanding that insurance from either companies do not want to pay for it?

I'm curious if you ever got your question answered and if so what were the steps you were given in order for aetna to pay for it. I'm also switching from BCBS to Aetna POS ii. Any advice would be helpful. Thanks! 

I am actually in the process right now of doing a 3 month program through my hospital where they have it specially setup to cater to the 3 month program, which I hope this helps me out in the end for the approval process!

I was wondering this same thing.