Aetna PPO?

First I called and spoke with 5 different reps and they all stated my company still covers wls. Thank God. My question is about the requirements what's the difference between the 6 month diet and the 3 month diet only you have to be on a low calorie and meet with a dietician. Also I read on this site that the surgeon performing the surgeon has to do the 3 month diet. But when I talk with my surgeon's office they told me no your pcp has to do it. Can someone please help me?Thanks in advance for any help. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in 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: Consultation with a dietician or nutritionist; and Reduced-calorie diet program supervised by dietician or nutritionist; and Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and Behavior modification program supervised by qualified professional; and 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 of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.) and For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery

Isn't Aetna fun? I e-mailed Aetna today with a description of what I had planned to do, and asked if my proposed program would meet their guidelines. The response was basically 'work it out with your doctor'. Well gee, thanks, I showed her the clinical bulletin (that you included in your post), and she's just as baffled as I am as to what exactly they want! The reply didn't point out that anything I had planned was unacceptable, though, so I think we're on the right track. Here's what I plan to do: 1. Meet with a nutritionist to create a low-calorie diet. The policy bulletin says it's supposed to be supervised by the nutritionist, darned if I know exactly what means! I think we'll be okay with just the initial visit, as long as the diet is written out and I can produce a statement from the nutritionist (remember, Aetna wants everything documented!). 2. Join a health club and use one of their certified personal trainers to create an exercise regimen. Once every four weeks, I'll meet with the trainer again to review and modify the regimen as necessary. I will keep workout notes and get statements from the personal trainer. 3. Every surgeon I've researched requires a pre-op psych clearance, and I think this plus the surgeon's pre-op program will qualify as behavior modification. 4. I'll see my PCP every four weeks for an update, official weigh-in, etc. She's going to maintain her records of what I do, just to back up my own documentation. I'm going to actually call Aetna tomorrow to try to get a straight answer, but I think my program will work. The behavior modification clause is the one that concerns me the most, since they don't bother to describe what they're looking for. However, I think the bariatric surgeon's pre-op program should cover that adequately. Now I just need to choose the surgeon! Here's the relevant text from the e-mail I received from Aetna: > It is suggested that you take a > copy of our policy bulletin to your physician and have him help you go > through the steps and do what he thinks needs to be done. Once you > think you have met the criteria, your physician needs to submit a > predetermination along with his office notes and office notes from each > provider of services involved in this task for the upcoming service. > For better benefits, be sure to use network providers. Documentation > from the services you mention, should be attached to the > predetermination when submitted. There's nothing in the (admittedly useless) Aetna documentation stating who should be in charge of this, your regular PCP or your bariatric surgeon. From the wording of the response and the policy, I'm strongly inclined to believe your PCP should be handling all this, although your surgeon's office will be the one submitting for insurance approval. Thank goodness my husband's employer purchased the WLS rider for 2005!

Kitty, You really need to join the Aetna wls yahoo group. They have the guidelines need for approval for both the 6 month and 3 month regimen. I'm doing the 3 month regimen, I will be meeting with my pcp, nutrition, personal trainer, and counselor once a month for 3 months and required them to noted everything we discuss and ask for a copy of it.