Questions about approval

[CaliRey95 7]

Beginning to get pretty frustrated. My insurance gives two options, 3 month program or 6 months program. Both have a different set of requirements. I completed the three month program, my insurance covered most of the procedures and I chose to pay out of pocket for nutritionist and Psychologist, about 400 total. What they're telling me is that it has to be 6 months and to disregard what my policy says. Any advice? Btw, surgery is scheduled May 1, and I start the liquid diet tomorrow.

[CaliRey95 7]

Here is a copy and paste of my policy stating the three month requirements:

• 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 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 dietitian or nutritionist; and
• Documentation in the medical record of the member’s participation in the multi-disciplinary 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 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 dietitian or nutritionist

[Alaska1980 10]

Did you figure out about the 90 day program?
I just finished mine and waiting for the doctors office to submit to Aetna.

[CaliRey95 7]

2 hours ago, Alaska1980 said:

Did you figure out about the 90 day program?
I just finished mine and waiting for the doctors office to submit to Aetna.

Well yes and no, my insurance says yes there is a 90 day program and if you followed everything, it depends on the doctor's notes entirely. They said it should get approved as long as my doctor outlines that I've complied and they believe the surgery is medically necessary.

They said if the doctor just provides a summary, that is not sufficient evidence for medical necessity with the 90 day program. I'm currently having this argument with my doctor, she doesn't feel like typing out notes for each of our visits.

[BKNEWJOURNEY2 3]

8 hours ago, Alaska1980 said:

Did you figure out about the 90 day program?
I just finished mine and waiting for the doctors office to submit to Aetna.

yo finished the classes as well and the tests

[Alaska1980 10]

I live in the middle of nowhere (100 miles to nearest town, I have to go 360 miles to see the surgeon) so I did not have any classes. I did see my pcp and nutritionist once a month, personal trainer every 2 weeks. Plus a weight loss counselor every week by video chat.

[M0214 21]

Did you figure out about the 90 day program?
I just finished mine and waiting for the doctors office to submit to Aetna.

Alaska1980 I did the 90 day program for Aetna. No issues getting approved

[M0214 21]

CaliRey is it your doctor’s office telling you to disregard your policy? Or is it your insurance?

My office wouldn’t schedule the surgery until I was approved ....

[Alaska1980 10]

My pcp was the one to suggest I try for the vsg but I do not think he has ever been apart of the process before. I can not type up the doctors notes but I did make sure we talked about everything that was supposed to be on the notes at every visit. Also I did type up a letter of medical necessity for him and he loved it.