Aetna Questions

I have been going crazy over the past year trying to figure out exactly what my Aetna plan needs in order to pay the claim for my and my daughter's WLS.  Can someone please clarify the following things for me?

1)  When they say, "For adults age 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), defined as any of the following: " does that mean that we have to have MONTHLY weigh-ins that we can show or only that we were overweight at a physicians visit sometime during the year (we can actually show several years' worth of physician visits where we were overweight, but not a continuous, 24 months worth of weigh-ins;

2)  I have heard people say that for the 3-month multidisciplinary program they only had to do visits with a nutritionist and the doctor and my daughter and I are starting on our third month seeing a nutritionist, the doctor, a person in his office (not quite sure what she does except talk to us about what changes we have made and what we are doing in terms of diet and exercise), and a psychologist to help us with behavior modification.  Do we have to have three months of a supervised exercise program where we meet with a trainer or physical therapist?  If we do, we will have to start the three months again and our insurance will run out at the end of December.

Also, the bulletin says that Aetna considers VSG medically-necessary when the criteria are met.    Our insurance is actually SRC, an Aetna Company, and they do NOT do pre-certification.   They define medically necessary as a procedure deemed necessary by a physician, etc. that falls under the accepted treatment for that illness, disease, etc.  When I call them, I am told one thing one time and something else another.   So, if we don't do something exactly right, I am afraid that they can deny payment.

So - does ANYONE know if we have to have 24 consecutive months of our weights or the doctor's say-so that we have had a BMI over 40 for 2 years and if we have to have supervised exercise sessions?

Thanks.

Marilee

Hi Marilee,

I was approved and so was my daughter on Aetna's 3 month multidisciplinary program.  We were both denied at first, we appealed, and the decision was overturned.  Both my son's are going thru the approval process right now.

When they say the presence of severe obesity that has persisted for at least the last  years you do NOT need to have had moonthly weigh ins.  Basically, you would need so show any doctor visits where your BMI was over 40 for at least 24 months and no where during that 24 months can your BMI have dropped below that or they will deny!  So yes, you just need to show several years worth of physician visits where you were at a BMI of over 40 with no co-morbidies.

For the 3 month multi disciplinary program, it has to be 90 days span of time from your first visit with your pcp and the dietician.  For myself and my daughter, we saw our pcp each month, and the dietician each month.  Count out 90 days from the time you saw them and make sure your last appointment is at least 90 days past that.  I was set up on an exercise program by a personal trainer, but I didn't not go to him regularly nor did my daughter.  It does, however, have to be documented in your physician notes that you are participating in an exercise program such as wlking , weight training, swimming, etc and the frequency, etc.

Hope this answers your questions....feel free to PM me if you have more questions.  I have samples of the letters we submitted for approval and also for our appeals.  The behavior modification one is tricky...make sure your physician is documenting in the office notes your behavior modification, such as not drinking with meals, joining support groups (OH), eating small portions, eating protien first, etc.....

Good luck to you!

Nan

I was diagnosed w/type II diabetes on Aug 24 ... does diabetic ed count as dietary counseling towards the Aetna presurgery requirement? 

thanks!