Doctor Supervised Weight loss...

[Guest guest]

I just got a call from my insurance company...Aetna HMO... and they

need to have proof that I have attempted weight loss doctor

supervised for at least 6 months consecutively over the last 2

years. Eventhough I have been to Weight Watchers a number of times

and attended more than 6 months with really no real success they

can't accept what my doctor says. They need records from WW and

guess what, WW doesn't keep records unless you are a lifetime

member. If I were a lifetime member I would not need this surgery.

So I guess I am going to have to join WW and start from there. This

just makes me so angry!! I have tried to loose weight my whole life

with no success but that is not good enough for them. Just a little

discouraged and needed to vent. But little do they know, I am not

giving up!!! I can do 6 months of WW standing on my head, it just

agravates me because that will push my surgery back even further.

[Guest guest]

Aetna changed their guidelines as of 02/04 and now they only require a

3month surgical preparotory regimen. My Dh had started the whole 6 month

supervised diet with his primary on Dec. and had seen a dietician. We

saw her once a month and completed the 3 months on March 8th. He also

did a Psych evaluation and submitted a referral letter from his primary,

and his orthopedist. The surgeon submitted everything on Thursday March

11th and we had approval March 12th. He had no other documented weight

loss attempts just the ones we listed on his paperwork to the surgeon.

Here is the link to Aetnas guidelines

http://www.aetna.com/cpb/data/CPBA0157.html and below I will post the

Surgical Preparotory regimen. I hope this helps you some. His

comorbities were high blood pressure, joint pain, pinched nerve caused by

the weight. He is 430lbs and 6'1 " tall. We have Aetna HMO also. If you

have any questions please let me know.

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:

Consulation 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 the member, and an 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.

[Guest guest]

Where did you hear this? I just talked to my case worker at Aetna and she was

still saying 6. Is there somewhere I can find that info. If that is true then

that is wonderful!!!! I would love some additional info. Never mind, I see the

link (don't know how I missed that) Thanks!!

Re: Doctor Supervised Weight loss...

Aetna changed their guidelines as of 02/04 and now they only require a

3month surgical preparotory regimen. My Dh had started the whole 6 month

supervised diet with his primary on Dec. and had seen a dietician. We

saw her once a month and completed the 3 months on March 8th. He also

did a Psych evaluation and submitted a referral letter from his primary,

and his orthopedist. The surgeon submitted everything on Thursday March

11th and we had approval March 12th. He had no other documented weight

loss attempts just the ones we listed on his paperwork to the surgeon.

Here is the link to Aetnas guidelines

http://www.aetna.com/cpb/data/CPBA0157.html and below I will post the

Surgical Preparotory regimen. I hope this helps you some. His

comorbities were high blood pressure, joint pain, pinched nerve caused by

the weight. He is 430lbs and 6'1 " tall. We have Aetna HMO also. If you

have any questions please let me know.

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:

Consulation 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 the member, and an 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.

[Guest guest]

Ok, I went to the site and read what you have on here. What is the difference

between Physician-supervised and Multidisciplinary surgical preparatory regimen?

Do you know? Does the second have to be through the place that you are getting

the surgery? I guess I need to call Aetna again because I am confused.

Thanks for any light you can shed on this.

[Dora Boyd] Re: Doctor Supervised Weight loss...

Aetna changed their guidelines as of 02/04 and now they only require a

3month surgical preparotory regimen. My Dh had started the whole 6 month

supervised diet with his primary on Dec. and had seen a dietician. We

saw her once a month and completed the 3 months on March 8th. He also

did a Psych evaluation and submitted a referral letter from his primary,

and his orthopedist. The surgeon submitted everything on Thursday March

11th and we had approval March 12th. He had no other documented weight

loss attempts just the ones we listed on his paperwork to the surgeon.

Here is the link to Aetnas guidelines

http://www.aetna.com/cpb/data/CPBA0157.html and below I will post the

Surgical Preparotory regimen. I hope this helps you some. His

comorbities were high blood pressure, joint pain, pinched nerve caused by

the weight. He is 430lbs and 6'1 " tall. We have Aetna HMO also. If you

have any questions please let me know.

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:

Consulation 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 the member, and an 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.

[Guest guest]

Dora,

Not much difference in the two. Like I said he started out doing the 6

month doctor supervised and then when they changed I called Aetna and he

had already done everything for the Surgical Preparotory Regimen, except

for the Psych Evaluation. As far as the Excercise goes our Primary just

noted in her notes every visit that he was following the dieticians

recommendations and how much he was excersizing.

Here are the guidelines and a small explanation of what he did:

1. Consulation with a dietician or nutritionist; and

Reduced-calorie diet program supervised by dietician or nutritionist; and

He saw the dietician one time and got her recommendations for a low

calorie diet. PCP documented in her notes also. Had to have a copy of

the dietician notes from that consult. Aetna would not pay for a

dietician for obesity but he had hypertension so they paid for it under

that.

2. Exercise regimen (unless contraindicated) to improve pulmonary

reserve

prior to surgery, supervised by exercise therapist or other qualified

professional; and

He just told our PCP how much he was exercising at each months visit and

had her document it in her notes.

I called Aetna to see who a qualified professional was and they said you

PCP is qualified or it could be a Physical Therapist of Trainer.

3. Behavior modification program supervised by qualified professional;

and

This was just a Psych Evaluation. Submitted the recommendation letter

from the Psychiatrist. This is not an absolute on the 6month physician

supervised, only if you have had psychiatric problems before and/or on

psych meds. It is mandatory for the surgical preparotory regimen but

there was nothing to it. He talked to the doc for an hour and that was

it.

4. 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.)

PCP documented at our first visit that he was seeking to have the Gastric

Bypass and just her observations of his overall health and the benefits

he would have if losing the weight. His compliance to the dieticians

recommendations and what those were and how much he was excersizing. She

did do a recommendation letter when we completed the 3 months that we

submitted along with the medical records for 5 years. They require a

documented weight for 5 years prior to surgery but DH did not have a

doctor documented weight for 2000 and 2001, but it did not make a

difference. I guess common sense would tell you if he was over 400lbs in

1999 and is still over 400lb, any weight loss did not stay off. She also

mentioned that he had lost less than 10% of his weight during this 3

month period.

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, 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.

This again is just the Psych evaluation which you will have done for #3

anyway.

We made sure we had all this before we had the surgeon submit. Again, we

submitted his medical records for 5 years back, of which 2000 and 2001

there was no documented weight(because scales could not weigh him- still

cannot but we counter balanced the scales they had with a stapler - I

weighed myself on their scale - weighed with the stapler hung on the end

to counter balance- subtracted the two. He weighed with the counter

balance and added back in the difference of my two weights. Works like a

charm.) We had his Psych Eval, the dieticians notes, his medical records

from his orthopedic doctor about his pinched nerve and joint pain and a

recommendation from him that losing weight would be beneficial, the PCP

recommendation letter, and whatever the surgeons office submitted. I

hope this helps some of you out. I would ask your rep at Aetna

specifically about it. I got one guys name, let me see if I can find it

who was very helpful .............. Okay his name was with Aetna

his extention is 14883, he was the only one over there that seemed to

know anything and I talked to several reps. He even called himself to

our PCP to get the referral for the Psychiatrist. Maybe he can help you

out. If you have anymore questions please feel free to ask.

Andra

[Guest guest]

Thank you for all the information. I am trying to look into every avenue and

every small loophole that they might use to try and deny. You have been of much

help.

Re: Doctor Supervised Weight loss...

Dora,

Not much difference in the two. Like I said he started out doing the 6

month doctor supervised and then when they changed I called Aetna and he

had already done everything for the Surgical Preparotory Regimen, except

for the Psych Evaluation. As far as the Excercise goes our Primary just

noted in her notes every visit that he was following the dieticians

recommendations and how much he was excersizing.

Here are the guidelines and a small explanation of what he did:

1. Consulation with a dietician or nutritionist; and

Reduced-calorie diet program supervised by dietician or nutritionist; and

He saw the dietician one time and got her recommendations for a low

calorie diet. PCP documented in her notes also. Had to have a copy of

the dietician notes from that consult. Aetna would not pay for a

dietician for obesity but he had hypertension so they paid for it under

that.

2. Exercise regimen (unless contraindicated) to improve pulmonary

reserve

prior to surgery, supervised by exercise therapist or other qualified

professional; and

He just told our PCP how much he was exercising at each months visit and

had her document it in her notes.

I called Aetna to see who a qualified professional was and they said you

PCP is qualified or it could be a Physical Therapist of Trainer.

3. Behavior modification program supervised by qualified professional;

and

This was just a Psych Evaluation. Submitted the recommendation letter

from the Psychiatrist. This is not an absolute on the 6month physician

supervised, only if you have had psychiatric problems before and/or on

psych meds. It is mandatory for the surgical preparotory regimen but

there was nothing to it. He talked to the doc for an hour and that was

it.

4. 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.)

PCP documented at our first visit that he was seeking to have the Gastric

Bypass and just her observations of his overall health and the benefits

he would have if losing the weight. His compliance to the dieticians

recommendations and what those were and how much he was excersizing. She

did do a recommendation letter when we completed the 3 months that we

submitted along with the medical records for 5 years. They require a

documented weight for 5 years prior to surgery but DH did not have a

doctor documented weight for 2000 and 2001, but it did not make a

difference. I guess common sense would tell you if he was over 400lbs in

1999 and is still over 400lb, any weight loss did not stay off. She also

mentioned that he had lost less than 10% of his weight during this 3

month period.

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, 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.

This again is just the Psych evaluation which you will have done for #3

anyway.

We made sure we had all this before we had the surgeon submit. Again, we

submitted his medical records for 5 years back, of which 2000 and 2001

there was no documented weight(because scales could not weigh him- still

cannot but we counter balanced the scales they had with a stapler - I

weighed myself on their scale - weighed with the stapler hung on the end

to counter balance- subtracted the two. He weighed with the counter

balance and added back in the difference of my two weights. Works like a

charm.) We had his Psych Eval, the dieticians notes, his medical records

from his orthopedic doctor about his pinched nerve and joint pain and a

recommendation from him that losing weight would be beneficial, the PCP

recommendation letter, and whatever the surgeons office submitted. I

hope this helps some of you out. I would ask your rep at Aetna

specifically about it. I got one guys name, let me see if I can find it

who was very helpful .............. Okay his name was with Aetna

his extention is 14883, he was the only one over there that seemed to

know anything and I talked to several reps. He even called himself to

our PCP to get the referral for the Psychiatrist. Maybe he can help you

out. If you have anymore questions please feel free to ask.

Andra

[Guest guest]

Yes it was but under the health part of our insurance not the mental

health. He did need a referral of course. That at Aetna took care

of it for me. We have not paid for anything so far except the copay for

the Primary that we are required to pay. We do have to pay a 1250.00

program fee at the final consult before they will do the surgery, which

in my opinion is or should be illegal. It is suppose to cover his

aftercare program, nutrition classes , dietician afterwards, etc. I

asked if I could file it myself and he said yeah but that I would

probably not be reimbursed. Our insurance pays 100% so I think that

should all be included in the charges for the surgery. My husband thinks

it is worth paying though. Just a scam to get more money out of you in

my opinion though. But if it helps my husband it will be worth it and

this surgeon is suppose to be one of the best around.

Andra

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