can anyone approved by Aetna answer a couple questions for me?1

My main question is who/what qualifies for the exercise consult part if I'm doing the 3-month.  A trainer?  If so, do they just do a write-up to include with the approval packet? Or do their notes go to the PCP? 

I'm just trying to fast-track this a bit.  I have a consult with the surgeon on Feb. 22 (soonest I could get).  I've had a nutritionist that I've seen occassionally for about a year, and I saw her this month, and saw my PCP this month, so I was thinking that if I can add the exercise part, I knock off the first and second month before I've even seen the surgeon. 

The other option I suppose is to just wait and use only the people that the surgeon suggests, but then I don't get started until the end of February.  

Also, I've been paying for a trainer at a gym that I haven't really been using :(  It is still potentially a plan to get all of the stuff done for approval, but with exercising and following my nutritionist's plan, if I feel like I'm losing weight, I might just wait on the surgery.  But I have done so much research on it already and I am somewhat desperate to lose weight.  

I had a sleep study done a few months ago and I do have apnea (now have a CPAP machine).  BMI is 43, and I have 5 year weight history (with BMI at or above 40) so at least those are covered.  



My other question is regarding success vs. failure on the supervised weight loss.  If I lose weight, will they deny me? Or am I supposed to lose weight to show that I can be successful after the operation? 


Thanks for the help!

Hi!  I'd be glad to help you with your questions.  I was approved by Aetna and had surgery in March 2009.  My daughter, approved by Aetna and had surgery in May 2010 and my two sons both just had surgery in Dec 2010, both being approved by Aetna.  Three of us did the # month multidisciplinary program and my one son did the 6 month physician supervised diet.  So I pretty much have it nailed down as to what they are looking for with the 3 month MD program.  I will send you a PM that details what we did for our approval.

To answer your question about the exercise consult.  It has to be documented in the notes to the PCP.  I work at a place where we have health facilities right here.  I went to the health center and had an excercise specialist set me up on a weight training/cardio program.  I took a copy of that along with a letter signed from that person stating that I had been set up on an exercise program.   That is all that I did for the exercise part of the requirements other than my PCP documenting in her notes that I was continuing my exercise program set up by so and so.........

One thing to keep in mind is this is a 90 day program - not 3 months.  So Aetna will count out 90 days from the time you saw your physician and dieticien and go from there. 

As far sa the success vs failure on the supervised diet.....during my 3 month MD program, I gained 6 pounds.  My daughter dropped about 5 lbs and my sons each dropped about 10.  I don't think it matters either way! (as long as you don't drop enough to push your BMI under 40!!)

I'll PM you.  And feel free to ask any questions you may have.  Two of us were denied at first and I appealed and the decision was overturned, so I have experience filing appeals with Aetna too.  You have to make sure all your i's are dotted and t's crossed and it can be a very easy approval.  But if you don't, they will definitely deny. 

Sounds like you are well on your way to a good start.  Key thing to remember is your PCP is the one who has to keep everything in his/her notes! 

And they will be looking for the 'behavior modification' requirement.  I talked to my dietician and my physician about behavior modifications I was making (joining a support group, not drinking with meals, cutting out pop, etc....) and both of them documented it in their notes. 

Hope this helps!

Nan

hi there Nan.....i too will be dealing with Aetna....i have to do a 6 month PCP visit count.....anything you can send me i would so appreciate!

I too was approved by Aetna, but it was after 2 appeals.

I agree with everything Nan says and used some of her letters to help get my approval through.  I agree, get everything documented, take it to your PCP and get them to clearly document your efforts in each of the three areas in their notes.  This would typically be sent with the surgeonsrequest for the actual surgery.  I also sent the visit verification from the counselor I went to.

The 90 day vs 3 month or 180 days vs 6 months is very true and important.  They will deny you over just this....

Good luck!

I had my surgery 12-21 and am down over 50 lbs already! ; )