To hell and back with Aetna

Aetna policy states this in reference to supervised diet: Member must meet either criterion a (physician-supervised nutrition and exercise program) or criterion b (multidisciplinary surgical preparatory regimen): a. Physician-supervised nutrition and exercise program: Member has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria: i. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and ii. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration, with participation in one program of at least three consecutive months, prior to the date of surgery. (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 iii. Nutrition and exercise program must occur within the two years prior to surgery; and iv. 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; or b. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in an organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions: i. Consultation with a dietician or nutritionist; and ii. Reduced-calorie diet program supervised by dietician or nutritionist; and iii. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and iv. Behavior modification program supervised by qualified professional; and v. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment the member, and an assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.) I was originally denied by Aetna because I didn't have a total of 6 months of a supervised diet and exercise program. Well, my doctor and I went over the policy and he said that we could go either way, criterion a or b. Well, I submitted my appeal with this quoted into the appeal letter and noted that my surgeon has placed me on the multidisciplinary surgical preparatory regimen (criterion b not a) which states that you need to be on this at least three months prior to surgery. It does not state that you need this plus any additional time on a supervised diet plan. Can anyone tell me what is the difference between the two besides time...... I'm so frustrated and depressed at this point because I mailed my appeal letter certified on May 17th and they signed for it on May 20th and come to find out they can't located it (not surprising). I got so mad and called everyday until one rep asked me to mail it directly to her. I did this on June 16th and they got it on the 19th but it didn't reach the lady until Monday evening on June 21. I have since then called everyday and expressed my frustration and anger and told them that I wished to have this expedited because they have miss the deadline. I also told them that I would expect to hear something soon because if the table were reversed, it would have been oh well for me. Pray for me....

Krecia, I'm with you. I was denied by Aetna due to no evidence that I was on a diet for six months. I have been going to a weight loss doctor since 6-02 and they still denied me stating that I didn't show any evidence that I was on a diet. Come on !!!! I'm going to a weight loss doctor to lose weight but no diet. Come on. I think this is crazy personally. I filed an appeal June 17 and they still haven't responded other than it's in review. I will pray for you. I know what you are going through. Good Luck !!!! Shondra

So, Shon, I don't get it? What do you mean Aetna says there's no evidence that you've been on a diet. Don't you have medical records? Or did they lose your records? I'm asking because I'm in the process of doing the six month diet that Aetna wants and I don't want any trouble getting approval. I plan on making lots and lots of photo copies of all my medical records. please email me and tell me what happened to you, ok? Lynda D.

I'm trying to find a doctor. I have received a referral from my doctor (PCP)and everyone that I thought I could use, has turned me away due to my Insurance with Aetna HMO. I even called Aetna, and asked them to give me a list of Doctors that are in there plan that could help me with this and of course they gave me the names of gastrologist. They could not tell me if they doctor performed the Gastric Bypass Surgery or not. It's frustrating and discouraging when you are trying to do something to better yourself and only to get stopped at the door. Help Chandra

I have a question for you, I am doing the Multidisciplinary surgical preparatory regimen and I have a week before I hand in my paperwork to the insurance. There is one thing that I did not do and that is the "Behavior modification program supervised by qualified professional" I showed it to my regular doctor and she didn't even know what this was. Can you give me some insight as to what this is so I can get moving on that part asap. Thanks for any help Renee

Hi, I was so glad to see this! I am just starting out and I went to my PCP for what I though would be a physician supervised weight loss program. I discussed the WLS with him and he agreed that it was something I needed and supports my decision. I showed him the criteria you referenced and he said that under their definition he would not qualify since he does not work with a dietician. So, I was planning on going to option b, but how do I know if my surgeon meets this criteria? I am planning to start the process once I get my paperwork into the Doc to set up my initial appointment. He has a set program that sends me to multiple specialists that seem to meet the criteria. I think it is going to come down to the actual documentation. Wish me luck! And please let me know if your approval comes through. Deb Coe.