Your Aetna experience?

If you click on this link it will take you to the aetna website and show you the requirements for the surgery Obesity Surgery

Yes, they probably will not take that from that long ago. I used my PCP with the six month diet. I also was required by Aetna to see a nutrionalist, have a phyc eval and go through several classes with the Surgeons office. I am just glad that it is all done and only have 3 weeks before my surgery.

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2/12 Have to do 6 mo diet again (PCP did not record all months weight)
04/09 Steps for Success
04/28 Nutritional Eval, Physc Eval
06/25 Submit to Aetna for Approval
07/10 Approved!!!!!!
08/18 Surgery

Jennifer, I will make the assumption that the basic Aetna diet and exercise requirement applies to your policy. So, you should see your primary care physician and have him start you on a 3 month diet and exercise plan. Have monthly visits and be sure he notes the diet and exercise discussion in his office notes. This is what Aetna wants to see. If you end up having to do 6 months, you will have 3 under your belt. If only 3, then you have that part done. Good Luck! Tom

I found this on te Aetna website..

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.)