Aetna Choice+ POS II- 3 month documentation (again)

Hi all-

ok- my husband and I are working on the Choice Plus POS II documentation for him, hoping to go for the 3 month program instead of the six:

So my understanding is:

doctor supervised diet and exercise - clearly documented
nutritionist
psycholigist
exercise physiologist


all well documented with office visits at least once a month

does this sound right?  Does anyone know any specifics on how the documentation looks?

Thanks for your help!

HI,

I was approved on the 3 month multidisciplinary program and yes that sounds about right.  Aetna does not require the psych testing though but the do require on the 3 month program documentation of 'behavior modification' so make sure your doctor is documenting that in his notes.    I will PM you with all of the documentation I sent.

Hope this helps.

Nan

 

Could you please PM this info?

Thanks,

Andrew

I will PM you the info . 

Andrew - I can't PM you because your profile is set as private.  Here is the info I was going to PM you. 

Here is a summary that I wrote up for someone else a couple weeks back….I'm just sending you everything I have. The letters at the bottom, if I were you, I would type them up and take them into your PCP to sign. Submit them with your paperwork (reword them for your cir****tances!)  
*First step is the PCP.
-Weighed in with her once a month (it needs to be as close to exactly one month apart as possible).
-You'll need 4 visits, because the first 1 doesn't count, as it is not a month.
-My doctor kept VERY detailed notes such as I was exercising ___ times per week, for _____ long.
-It also listed methods being used to comply with the regimen - low calorie diet, as prescribed by the nutritionist. I did join WW, but I don't think it was necessary.
-The check list also had my height, weight, BMI, and diagnosis of obesity on it.
-I also composed letters which my PCP signed, detailing what I had been doing that month to abide by the requirements. (Those are at the bottom of this email).

*As far as the nutritionist, I was able to see a dietician where I am employeed. I met with her once a month and she took notes and went over the bariatric eating pre and post op. I made copies of the notes she took and had them faxed to my PCP. Make sure the PCP includes these notes in her notes. What the guy from Aetna told me was they need to be 'working together' . Even though my PCP and dietician never spoke on the phone, I'll send you a letter which my dietician and exercise therapist sent to my PCP. 
-You'll need 4 visits with them too, just as with the PCP.
*As far as office notes, my NUT submitted a page for each visit detailing what we had talked about as far as dietary changes AS WELL as behavioral changes, such as eating our of boredom, changing to healthier food choices, etc. The behavioral changes requirement was the most confusing part to me, because nobody at Aetna could tell me what they were looking for, but apparently this worked. But I was told, you must meet this requiremnt or you will be denied. So I made sure both the dietician and PCP were documenting my 'behavior modifications' such as a) joining an online support group (OH), b) joining a local support group c) increasing my fluid intake

*The same thing with the exercise specialist. I used one affiliated with my place of employment. We have a gym we can join so I joined the gym and went to the exercise specialist who set me up on a weight training and cardio program. I drafted a letter signed by him to give to my PCP so she could document in the notes that I had met that requirment. I'll send you that letter too.

*I also did the psych eval, which is required by Aetna.

*One thing I would have to say is to be proactive and make sure you stay on top of these appointments. Some practices have coordinators that do that, but I was responsible for making all of mine. I was glad, though, because I knew exactly what steps I’d completed and what was left to do.

*So, in a condensed version:
I saw my PCP once a month for 3 months, after the initial visit.
I say my NUT once a month for 3 months, after the initial visit.
I saw a exercise therapist once or twice.
and I saw a Psychologist once.

*The info submitted to Aetna was:
Office notes and a letter for each PCP visit
Office notes for each NUT visit
Exercise specialist's note.
Psych eval letter
Medical history showing 2 years proof of obesity. Letter of medical necessity from PCP

I know this is a lot of info, but I hope I have broken it down into manageable sections. PM me if you have any additional questions and I'll be glad to help. I am so thankful that I was able to have this surgery that I am just trying to "pass it on".

These were the letters submitted along with the office notes.  They are just samples and you can change them to reflect your specific information
: Date AETNA
P.O. BOX 14079
LEXINGTON, KY 40512-4079 To Whom It May Concern: On Sept 29, 2008, I saw XXX for her initial visit to begin the multidisciplinary surgical preparatory regimen for bariatric surgery. Among the issues discussed today were dietary changes, exercise, and behavior modification that will contribute to success with the procedure. Mrs. XXX is scheduled to see a physical therapist for an exercise evaluation on October 13th and will see a dietician on Oct 14th. She will also attend bariatric support group meetings. The patient was counseled that implementation of the changes discussed are vital in order to improve her surgical outcome and reduce the potential for surgical complications, as well as establishing her ability to comply with post-operative medical care and dietary restrictions. Mrs. XXX is scheduled to return in one month. Dr. XXX ------------------------------------------------------------------------------------------------------------ Date AETNA
P.O. BOX 14079
LEXINGTON, KY 40512-4079 To Whom It May Concern: On October 25, 2008, I saw XXX for her first monthly visit in compliance with the multidisciplinary surgical preparatory regimen for bariatric surgery. Since her last visit, Mrs. XXX has seen exercise specialist, XXX, who conducted an exercise evaluation and developed an exercise regimen for the patient. Mrs. XXX is exercising three times per week by walking and following the regimen prescribed by XXX. Also, since her last visit, Mrs. XXX has seen dietician XXX, who developed a reduced calorie diet program for her. In addition, she has attended support group meetings which are designed to address the behavioral changes necessary for success with the bariatric procedure. Mrs. XXX was counseled on the importance of continuation of these changes to help ensure success with the procedure and is scheduled to return in one month. Dr. XXX ------------------------------------------------------------------------------------------------------------ Date AETNA
P.O. BOX 14079
LEXINGTON, KY 40512-4079 To Whom It May Concern: On Nov 23, 2008, I saw XXX for her second monthly visit in compliance with the multidisciplinary surgical preparatory regimen for gastric bypass surgery. Since her last visit, Mrs. XXX has continued working with dietician XXX, as well following the exercise regimen developed by physical therapist XXX. In addition, she has also been walking 30 minutes per day, three times per week. Mrs. XXX continues to attend bariatric support group meetings which discuss the behavioral changes that are required of successful bariatric surgical patients. Mrs. XXX was counseled on the importance of continuation of these changes to help ensure success with the gastric bypass procedure and is scheduled to return in one month. Dr. XXX ------------------------------------------------------------------------------- Date AETNA
P.O. BOX 14079
LEXINGTON, KY 40512-4079 To Whom It May Concern: On December 29, 2008, I saw XXX for her third monthly visit. She has completed the three month multi-disciplinary surgical preparatory regimen including a reduced calorie diet, exercise, and behavior modification, designed to increase her pulmonary reserve, improve her surgical outcome and reduce the potential for surgical complications, as well as establishing her ability to comply with post-operative medical care and dietary restrictions. Since her last visit, Mrs. XXX has continued working with dietician XXX, and has been following the exercise regimen developed by physical therapist XXX. In addition, she continues to attend bariatric support group meetings. Mrs. XXX has been compliant with the multidisciplinary regimen and has made positive changes for her health. I recommend proceeding with the gastric bypass surgical procedure. Dr. XXX  

Thank you so much. I went through this process about 8 years ago. I had Aetna HMO, they covered it when I submitted everything but they denied me twice pushing me into a new year where they no longer covered the procedure. Haven't been able to get the weight off since then....Switching to Aetna POS II, Plan B, they cover a one time $25,000 for bariatric.

I plan on getting started with the prework by 1st of November so that I can hopefully qualify for the surgery by spring. My current weight is 300 lbs, I'm 5'8", BMI is 46.7. I have sleep apnea, high triglycerides/cholesterol, plantar fasciitis just to name a few comorbitities.

Anyway, thanks again for your help I will keep you posted.

 

Andrew Vargas
La Porte, Texas

Hi there,

I also have Aetna, I did the 6 month plan, and they denied me because they didn't see exercise program documentation.  I am now doing the 3 month bariactric weight loss program through OHSU, do I need to go to the doctor at OHSU during my 3 month program? 

thanks!

Fred