aetna new stuff required it seems

I am in the process of getting the preop stuff ready
I am trying for the 3 month fast trac, however if it takes 6 months then so be it
well today I was on the aetna site and pulled up the policy 157 their guidelines... and they have modified it
there is much more involved now
did anyone else notice this
so I called my surgeon to ask them and they were like... we will need to review it and we will call you back in 1/2 hour, I called them after 3 hours and they said they were still reviewing the changes

so based on the way I read it the two months I have completed, documented and seen multiple drs may be for not and I may have to start over again, yes I am thankful I have insurance... just a bit concerned

so... has anyone else noticed this change and what did your dr say

thanks M

I have UHC, not aetna - -- but - - - - there were changes to my ins. requirements that my surgeon was not aware of.  I can tell you that you MUST be your own advocate and do not rely on the surgeon's office to tell you what your insurance requirements are.  I love my surgeon and staff, but I must follow my insurance bariatric nurse's instructions to meet requirements.  I think WLS is becoming much more popular and the insurance companies are become stricter.  Please, please be SURE you read and document everything and follow to a "T".  I might be a little paranoid of insurance companies, but I do not want to have to start over with this process, so I keep copies of EVERYTHING and make meticulous notes.

I was approved by Aetna and so was my daughter and both of us did the 3 month multidisciplinary program.  What has changed??  I followed the clinical bulletin 0157 to make sure we met all the requirments.  Basically, had to show a 2 year history of obesity, meet with a dietician, monthly visits with the physician, both of whom documented a reduced calorie diet, exercise, and behavior modification.

What changed with it?

I pulled up the bulletin and compared to my old printout (from 2/15/10) -- regarding the 3 month multidisciplinary requirement (fast track) they changed the "3 consecutive months duration" to "90 days". 

I was scheduled to complete my 3 mo program on May 6th.  The hospital I am completing the program with has a sizeable bariatric surgery center, and they have always been under the assumption that as long as you have an appt in 3 separate months, you meet the 3 month timeline requirement.  So - if you start at the END of March, have an appt in April, then the last appt at the beginning of May - you meet the 3 month requirement (even though the true duration of the program would have been around 45 days).  My guess is they have changed the wording to force the 90 day duration. 

I am calling the surgeon's office on Monday to find out what impact this will have on my schedule....I have no idea what to do - maybe I will have to have an additional appt in June? 

Also, I did call Aetna to find out if I could get clarification...and the rep really had no clue about it (though she was really nice).  Her recommendation was to submit for approval as originally scheduled - and see if it meets the requirement or not.  Great. 

Good luck,
Melissa

Hi,

I just wanted to let you know I was approved on Aetna's 3 month multi disciplinary program back in Jan 2009.  I was denied first though because my surgeon's office submitted my paperwork too soon.  I called and talked to a representitive from Aetna who said 'make sure it is 90 days duration and no sooner or you will get denied.'  So even though the clinical bulletin at the time said 3 months, I think it really meant 90 days.  He told me if you submit and it was only 89 days between your first appointment and your last apointment you will get denied, so make sure it is 90 days or more. 

Better to be safe than sorry, so I would count out 90 days from the first time you saw your PCP and make sure your last appt is at 90 days, or more, from that day.  Then there will be no question about it. 

And the rep telling you to submit and see what happens, that is great, unless you get denied, because then you have to go through the appeal process, which takes time. My daughter and I were both denied  We both appealled and won our appeals, but it tacked on an additional 30 days in the process of getting approved.  If I were you, I wouldn't submit until you have completed the 90 days and save yourself the stress of having to appeal.  Just my opinion, having been through it twice already!

Nan 

HI Nan!  I just wanted to follow up on this post.   I did get denied!  However, they did not have issue w/the 90 days.  It was due to my BMI history.  The only time I was weighed in 2008 was after losing weight on WW, and my BMI was 33.  So now I will have to appeal.  I didn't see any other physician in 2008, and unfortunately did not get my weight documented BEFORE starting WW (then I'd be set). 

So next we will start the appeal and argue that the change in BMI was temporary and not sustainable (as documented by later weights). 

What a pain!  If it's not one thing, it's another!!

Hi Melissa,

Thanks for the update.  So DON'T give up.  I will PM you a sample of my appeal letter that I sent to Aetna.  Think hard, do you have anything at all that would have your documented weight other than WW where your BMI is higher in 2008??  Maybe even a date stamped photo you could send along with your appeal letter?

When was your documented weight in 2009?  Worse case scenerio is you have to prove 2 years history from that point.  Just don't stop going to the PCP for your monthly visits until you get approval because you don't want to start this whole process over if you lose the appeal, meaning, if you continue going to your PCP for 3 more visits you'll have the 6 month physician supervised diet done (vs the 3 mo Multidisciplinary program)  So if you have to pu**** into 2011 so you'll have documented weights in 2009, 2010, 2011, then you will have the 6 mon physician supervised diet done. 

I'll PM you.

 

Nan

 

Follow up:

NAN IT WORKED!!  I used your letter and modified for my case.  I didn't have any additional weight docs, but I just spelled out the weight history in my letter (skipping the physician office weight that was below 40 BMI and instead listing the WW weight) and as you suggested submitted ALL of the documentation again by myself. 

I also took your advice and wrote a letter for my PCP to sign (he's too busy to write one himself).  That probably did help as well.

I submitted the appeal on 6/9/2010 and my due date was 6/25/2010.  I knew they had 30 days to decide, but last week when I called to check on it -- the rep said someone had entered in the 25th as the due date...so maybe once they get it in their queue it could be sooner than the 30 days.  I did call periodically to check on the status, but no decision until EXACTLY on the 25th in my case.

So NAN, I can't thank you enough for your help!  You are a real gem!!

Sincerely,
Melissa

The wording wasn't as specific when I was working the 3 month regimen about a year and a half ago. 

I actually went into a 4th month in my qualifying because the policy didn't specify either way at the time and I wanted to be sure.  I suggest that you go 90 days because it's just too discouraging if you do a little less and the insurance company disagrees or wants to nit pick.

It's easier to voluntarily extend things a few weeks than have them drag it out a lot longer because of something like that.