Angie M

I'm July 31 - pending insurance approval! It was submitted last week. Getting excited!

Dr. Nestor De La Cruz-Munoz at University of Miami

So.... as it turns out, when you cease to qualify for the 4 month prep plan (because you did not fulfill the 3x week exercise routine), you then shift into a 6 month prep plan, which only increases the number of visits to the nutritionist, and no longer has any insurance requirement. I think that's totally weird but oh well! At this point I am exercising 2-4 times a week depending on my schedule. I completed my upper GI on Monday. Oh, and great news! The GI discovered that I have a small hernia, which is the explanation I will give to people when I let them know I am taking two weeks off for surgery!! Yahoo!!! I never knew I could be so happy to have a hernia! And finally, my therapist (in lieu of group sessions) completed and mailed her letter of support. So, when I go back to my nutritionist meeting (#5 out of 6), I should be ready to start scheduling! It's starting to become real!

Found online: Number: 0157 Policy Note: Most Aetna *** 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. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Sleeve Gastrectomy, Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures: Aetna considers open or laparoscopic short or long-limb 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: Must meet either 1 (adults) or 2 (adolescents): For adults aged 18 years or older, presence of persistent severe obesity, documented in contemporaneous clinical records, defined as any of the following: Body mass index (BMI) (see appendix) exceeding 40; or BMI greater than 35 in conjunction with any of the following severe co-morbidities: Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); or Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or Type 2 diabetes mellitus For adolescents who have completed bone growth (generally age of 13 in girls and age of 15 in boys), presence of obesity with severe co-morbidities: BMI exceeding 40 with one or more of the following serious co-morbidities: Clinically significant obstructive sleep apnea; or Type 2 diabetes mellitus; or Pseudotumor comorbidities BMI exceeding 50 with one or more of the following less serious co-morbidities: Medically refractory hypertension; or Dyslipidemias; or Nonalcoholic steatohepatitis; or Venous stasis disease; or Significant impairment in activities of daily living; or Intertriginous soft-tissue infections; or Stress urinary incontinence; or Gastroesophageal reflux disease; or Weight-related arthropathies that impair physical activity; or Obesity-related psychosocial distress. Member has attempted weight loss in the past without successful long-term weight reduction; and Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen): 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: 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. Records must document compliance with the program; the member must not have a net gain in weight during the program. 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 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 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 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.) or Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 consecutive 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: Behavior modification program supervised by qualified professional; and Consultation with a dietician or nutritionist; and Documentation in the medical record of the member's participation in the multi-disciplinary surgical preparatory regimen at each visit. Records must document compliance with the program; the member must not have a net gain in weight during the program. (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 multi-disciplinary surgical preparatory regimen.); and Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and Program must have a substantial face-to-face component (must not be entirely delivered remotely); and Reduced-calorie diet program supervised by dietician or nutritionist. 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, 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 post-operative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery. Vertical Banded Gastroplasty (VBG): Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co-morbid medical conditions: Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or Hepatic cirrhosis with elevated liver function tests; or Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix); or Radiation enteritis. Aetna considers VBG experimental and investigational when medical necessity criteria are not met To read more: http://www.aetna.com/cpb/medical/data/100_199/0157.html

I hope that's what it is. I did try to find it on Aetna's website to verify.

Glad to know I'm not the only one feeling the pressure. At this point it feels like a "well, we'll let you know if you can have it or not based on if you follow the rules!" Well, the rules aren't working. Otherwise I wouldn't be here. Congrats to you on your success! I have a weigh in tomorrow and know it won't be good. There's no excuse - even if I was traveling on business for a week, sick for a week, and celebrated my birthday all in the last month. Life happens!

I had actually done the sleep study on my own last November and they didn't seem to emphasize much about it - and I now I do sleep with a mask. It's so confusing! Thanks for your insight.

Hi I wanted to know if this is typical for people who have Aetna insurance in Florida or if it has been enhanced by my doctors office. I had my initial consultant in in January. I was told that my insurance requires that I have six monthly appointments for the nutritionist, one psych evaluation, and participate in six bariatric group sessions or see my own psychotherapist to cover the same topics. I had to follow a 1400 calorie diet, which I have not done successfully, in order to remain the same weight or lose weight from my initial weigh in. I cannot weight even one pound more or the insurance will not cover it. Finally, i have to exercise 3 times a week. I'm averaging 2-3 times but not consistently and I'm worried about being denied. Nevermind the judging I get from the nutritionist. I have another meeting this Monday and am a bit nervous. Should be scheduled in July if all goes well. Anyone experiencing this? I saw this the legitimate requirement or are they increasing it so I have better habits later? Any insight is welcome! Thanks!