Is it Aetna or Drs Office Personel?

I am having a bit of trouble with my surgens office understanding the policy....if things are inblue i have done them, if not....I havent completed that.  tell me if i am not getting something,

 

 

Clinical Policy Bulletin:
Obesity Surgery
Number: 0157


Policy

Note: Most Aetna HMO and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. Please check benefit plan descriptions for details.

1. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures:

   Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), 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. Presence of severe obesity that has persisted for at least the last 2 years, defined as any of the following:

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

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

         1. Coronary heart disease; or
         2. Type 2 diabetes mellitus; or
         3. Clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or

         4. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

      and

   2. Member has completed growth (18 years of age or documentation of completion of bone growth); and
   3. Member has attempted weight loss in the past without successful long-term weight reduction; and

   4. 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. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
         2. Nutrition and exercise program(s) must be for a cumulative total of 6 months 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.); and

         3. 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

      2. 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:

         1. Consultation with a dietician or nutritionist; and
         2. Reduced-calorie diet program supervised by dietician or nutritionist; and
         3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
         4. Behavior modification program supervised by qualified professional; and

         5. 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

   5. 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 (doesnt pertain to me!!), 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

   So here is what i dont understand.  I have 6 months of history, and i have 3 months in a row....but I dont have 6 months in a row and the lady that files the insurance says that i have to, but in this bulletin it doesnt say 6 consecutive months.

What else do I need to do in order to satisfy these people!!

 

I am almost in tears writing this!  Jeez!!

Hmmm...my Aetna program only required a 3-month doctor-supervised diet/exercise plan prior to submitting to insurance (which would be the "three consecutive months" thing).  As for the "cumulative total of 6 months within 2 years of surgery", my doc had me fill out a form his office had created that listed all the diets I'd been on for 2 years.  Needless to say ther were a lot LOL.  To me, it sounds like your policy is saying you must have attempted to diet for 6 months or longer within two years of surgery, with at least ONE of those diets lasting a full 3 months (typically, the last one prior to surgery).

To me, it sounds like yes, you have met the criteria.  I know many insurances do require 6 CONSECUTIVE months and maybe the office staff is confused?  My office actually specialized in Aetna so luckily they knew the policy inside and out.  I would say you have two options:
1. Email Aetna through their website, specifically state your question, and when they validate you, print it and take it to your doc's office.  It is important you get this IN WRITING, from Aetna.  They're usually pretty good about contacting you back quickly.
2. Post this on the insurance board here at OH.  There are a lot of members who actually do Insurance for a living and can put this in layman's terms (and tell you if you're right or wrong).  But still, you'll want to have Aetna's answer to prove your doc's office is wrong and they need to submit your paperwork).

I am sure you're very frustrated but try not to let it get to you.  Part of this process IS on us and we have to do the legwork sometimes.  For every office that is on-the-ball, there is an office that doesn't know its ass from its elbow.  So do your homework just a little more, and hopefully you'll get your way sooner rather than later.

You are in the same boat I was in.  I ended up having to do the 90 day surgery prep, with my pcp and the dietician.  Once that was completed, I was approved.  And even though Aetna doesn't state that in their terms, it does have to be 6 consecutive months.  Aetna is bad about putting it clear in what they require.  I spent a few hours talking to different people, in tears trying to get them to explain what in the hell it meant in their requirements and they couldn't even make sense over the phone.  I had one lady hang up on me because she wasn't making sense and I told her that.  I told her what she was telling me was required, that I had done.

But my surgeon's office knew what Aetna wanted, and I had to do it before they submitted it.  They didn't want to have them decline it.  So I did it, frustrated as hell, I did what they said I had to do.  Got it done, it was approved 3 days after it was submitted to Aetna!! 

 You just wait honey, I know going through all of that makes it seem like it will never happen, you will want to just give up, but trust me, its sooooooooooo awesome when you find out you are approved.  Its like hearing you won the lottery, I swear.  I was at work when I found out and I squealed lol. 

Just don't give up!  It will be worth it, I PROMISE!

well i went today to another a weight loss clinic, basically all they do is prescribe diet pills so i am starting a 3 month pre op diet...again.  grrrr.  i am going to see a shrink and a physical therapist, and a nutritionist all at the same time each month.  and then AETNA will not be able to deny me!

So your surgeon doesn't have a team of these professionals that they are working with?  Go to the shrink and tell them that you need a psych eval done because you are needing it for approval for gastric bypass.

Then for the 3 months pre-surgical prep part.  Go to your PCP and tell them that you are going to be on a diet/exercise program closely followed by a nutritionist, and have him weigh you, and tell him what "diet you are on" and what exercise you will be doing.  And then go to the nutritionist.  Go monthly to the nutritionist.  THEN after your final visit with the nutritionist to complete the 90 days, GO to your PCP and have them notate what all you did, and have them weigh you, and then have them write a recommendation letter saying that they believe the only thing that will help you is to have this WLS done.    Then, have the nutritionist and your PCP fax over all there documentation to your surgeon's office.  It will go by faster than you think.  You will learn about chewing 20-30 times on each bite, and you will start to eat less because you will get tired of chewing.  Make sure you get exercise at least 3 times a day.  You will work on not drinking before, during and after meals.

The psych eval will take maybe a visit or two.  Its not that hard.  Just be yourself.  IF you have anymore questions, message me.  I just went thru all AETNA's **** this year.  :-)