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Aetna has published new guidelines for Bariatric surgery!!!



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Hey everybody, I just started my journey this week! The good news is Aetna, my insurance company, and probably many of yours, has revised their obesity surgery guidelines effective May 1, 2020. They have removed the need for weight loss or maintenance of 3 months or 6 months, and now only require 12 intensive appointments in a multi-component program that you are most likely already in the middle of :) So great news...

I also talked to the insurance peeps yesterday and asked specifically about the 12 intensive appointments, and they said, it was just a number to guarantee that you were an established bariatric surgery patient following a program, but that the new guidelines were now just based on approval of completing your doctors program!!!!!! Spread the word, you could be a lot closer to a surgery date than you thought :)

I have attached the url to the medical bulletin below :) http://www.aetna.com/pharmacy-insurance/healthcare-professional/documents/obesity-surgery-precert-form.pdf

On April 21, 2020 this revision was made on the medical bulletin and can be found here http://www.aetna.com/cpb/medical/data/100_199/0157.html#dummyLink2, under the review history on the right side bar, then look for 04/21/2020
"This CPB is revised to state that bariatric surgery is considered medically necessary when criteria are met and member has participated in an intensive multicomponent behavioral intervention designed to help participants achieve or maintain weight loss through a combination of dietary changes and increased physical activity. The intervention must be intensive (12 or more visits) and occur within 2 years prior to surgery. This CPB is revised to remove the requirement that the member maintain or lose weight during this program. This CPB is revised to state that bariatric surgery for is considered medically necessary for adults with a BMI greater than or equal to 35 with nonalcoholic steatohepatitis (NASH), and for adolescents with a BMI greater than or equal to 40 with NASH, when criteria are met. This CPB is revised to require cardiac clearance, obstructive sleep apnea screening, and optimized glycemic control as prerequisites for obesity surgery."

I SOOOOOO Hope this makes someones day :) So glad to be here!

Aetna PreCertification.pdf

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That is wonderful news! I have Aetna and did have to complete the 6-month program. It was frustrating, because I once I made the decision to have surgery I wanted it to happen ASAP. (Best decision I ever made, by the way.)

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Are you in California? I have Aetna also but my Dr’s said that the 12 steps were additional to the 3 or 6 month program!

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Hi! I’m in Oregon. You may want to call your Insurance and get a clear answer yourself or show them the new pre certification form, I had to as my medical team was confused too. When I spoke to Aetna they told me the only requirements now are what are on the pre certification form linked above. The 4/21/2020 medical bulletin (copy and pasted above) removed the requirement of losing or maintaining weight during the 6 month previous requirement and now it’s just the 12 or more appts, including the cardiac clearance and sleep study in addition to the multi component program from your Dr (dietician, psych etc). The pre certification was effective May 1st, 2020 and when I questioned my surgery scheduler about it she was shocked she hadn’t been sent the new info and immediately called them to verify. I hope this helps :)

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I should also add, the 12 appts could take 3 months to get through depending on everyone’s schedule, it will for me, so maybe that’s what the drs meant?

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I really hope that is the case, thank you so much for responding. I will call Aetna today and see if what they say. 😊

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So glad I stumbled across this post. I have aetna as well, My dietician and surgeon are going off of the Aetna bulletin you posted (0157). The #3 on the bulletin has my dietician scratching her head... the " Program must be intensive (12 or more sessions over any duration of time) and occur within 2 years prior to surgery (Note: Programs may extend beyond two years if the final session occurred within two years prior to surgery); "

I'm curious ,if anyone else who had to meet that criteria, what kind of time frame you completed it in?

My dietitian wants to treat it as like a Weight Watchers or Jenny Craig program, basically once a week visits for checkup which would allow me to complete that in 3 months. Some of her colleagues are saying once a month for 12 months. I'm curious to see what experience others have had with the timeline of completing this.

Spoke to an Aetna rep today, he too is under the impression that 12 sesssion's means just that 12 sessions ... any time. Whether its 12 days back to back (although laughed and said probably wouldn't be beneficial but would satisfy the wording on the requirement criteria) , once a week, or once a month. IT WOULD ALL BE CORRECT.

If anyone could shed any light on this, please do so :)

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