After my first denial (the lady at the surgeons office said that the medical reviewer practically denies everyone) my PCP and that reviewer did a peer to peer and he requested my entire file-18 pages of info. Still denied it which was why it went back to East Ohio Conference. I don't know if they are self funded..but when I spoke with the lady at EOC she told me that she felt I should try optifast again...or a supervised hospital program...it just felt like it was her "opinion".

So, how would I request another peer to peer? Have my PCP contact the lady I spoke to at the East Ohio Conference?

I greatly appreciate your help.

And advice! I feel alone doing this!

Angie

Here are the guidlines that I got off their webiste. I followed these rules 100% along with my PCP. I just feel like I am stuck-but I know I did everything I could. I don't want to settle with another denial based on what someone "thinks" I should do. Frustrating. I feel like I will give up if I settle with it.

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Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.

Selection criteria:

1. Must meet either 1 (adults) or 2 (adolescents):

   1. 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: 

      1. Body mass index (BMI) (see appendix) exceeding 40; or

      2. BMI greater than 35 in conjunction with any of the following severe co-morbidities:

         1. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in CPB 004 - Obstructive Sleep Apnea in Adults); or
         2. Coronary heart disease; or
         3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); or

         4. Type 2 diabetes mellitus

   2. For adolescents who have completed bone growth (generally age 13 in girls and age 15 in boys), presence of obesity with severe comorbidities:

      1. BMI exceeding 40 with one or more of the following serious comorbidities:

         1. Clinically significant obstructive sleep apnea; or
         2. Type 2 diabetes mellitus; or

         3. Pseudotumor comorbidities.

      2. BMI exceeding 50 with one or more of the following less serious comorbidities:

         1. Medically refractory hypertension; or
         2. Hypertension; or
         3. Dyslipidemias; or
         4. Nonalcoholic steatohepatitis; or
         5. Venous stasis disease; or
         6. Significant impairment in activities of daily living; or
         7. Intertriginous soft-tissue infections; or
         8. Stress urinary incontinence; or
         9. Gastroesophageal reflux disease; or
         10. Weight-related arthropathies that impair physical activity; or

         11. Obesity-related psychosocial distress.

2. Member has attempted weight loss in the past without successful long-term weight reduction; and

3. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

   1. Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

      1. 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; and
      2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
      3. Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (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.)

      or

   2. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multidisciplinary surgical preparatory regimen of at least three months (90 days) 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:

      1. Behavior modification program supervised by qualified professional; and
      2. Consultation with a dietician or nutritionist; and
      3. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (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
      4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
      5. Program must have a substantial face-to-face component (must not be entirely delivered remotely); and
      6. Reduced-calorie diet program supervised by dietician or nutritionist.

   and

4. 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, pre-operative psychological 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.