Question:
What does Aetna consider as a medical supervised diet?
For this surgery, I want to be sure to have approval from both my insurance companies. My primary is no problem, but it has a maximum lifetime limit. My secondary insurance is Aetna. They have a provision in the policy that requires a 6 month medically supervised diet within the past 2 years. My PCP is supportive of the WLS. His comment when I told him this is "what the heck do they mean by medically supervised?" I was able to document almost 30 years of diet history. My only medically supervised diets included Phen/Fen and the Blood Type diet with a naturalpathic physician. After the Phen/Fen fiasco (I do have a mild valve damage) I'm not sure I want to take prescription medication again and my PCP knows this. Of course I've tried a many other over the counter pills (I've stayed away from ephedra). I did do a 7 month stint at Curves that my PCP knew about within the past 2 years and he does know I work at losing weight since we talk about it regularly. I also have a thyroid problem and am on medication for that. Any suggestions as to what I can do for the insurance requirement? I won't ask my PCP to lie, but there might be some ethical things I can do with my past 2 years efforts or even any suggestions as to what I can suggest to him to do now, even if it puts things off for 6 months. — Helen C. (posted on January 4, 2003)
January 4, 2003
U Cal Irvine web site has a FAQ that may help. It says that A medically
supervised diet includes: a) a physician-directed diet and exercise program
to manage weight-loss;
b) participation in a dietitian-supervised group or individual program; or
c) treatment with medication prescribed by a physician in conjunction with
a diet and exercise program.
— John Rushton
January 4, 2003
Aetna gives different people different problems. I was lucky and my doctor
wrote a letter stating that for three months she put me on a 1500 calorie
diet and told me to exercise and she seen me at the end of the three months
and I had done what was asked of me but had only lost 10 pounds and that
was enough I got my approval. Good luck.
— Alicia K.
January 4, 2003
I do not have your insurance but mine also required a medically supervised
diet of 3 months. my pcp wrote a letter indicating all that and signed off
on 7 months worth. however my insurance didn't like that too much, they
denied me. they said it needed to say 1200 calories or less under a
medically supervised diet. i faxed them my weight watchers booklet of 3
months worth and called my doc for a new letter. although, i received
approval before my doctor even had time to write the letter so i don't know
if it was the weight watchers or what? they did tell me at the insurance
company that weight watchers is considered a supervised diet and the
calorie range is 800-1200 calories. good luck
— Dee ,.
January 4, 2003
I'm wondering if you Dr's office spoke with someone in the
pre-authorization dept or if they just spoke with a customer service rep.
There's a BIG difference. A lot of secondary insurance policies don't
require any pre authorizations...as long as they are covered by the
primary. You may want to call yourself and double check. Is the Phen-Phen
w/in the time frame? if so...USE IT lol...best of luck!
— Robin J.
January 5, 2003
Helen, I have Aetna POS and had the same exact provision in my
requirements.
All that means, and especially if you want to go into this prepared, is
that they need from your PCP copies (documented) in your files that you've
tried other diets.
In my case I was like you, I did the Redux (no vavle damage on me though)
and I also did Metabolife. Although the Metabolife was not supervised, my
PCP wrote a letter for me stating that I had tried several supervised diets
including some unspervised.
Seeing that you have vavle damage, make sure your PCP puts that information
along with any other co-morbidities you may have. (mine were sleep apnea
and arthritis in my knee). He (my PCP) also stated in the ending of the
letter that he believed it to be medically neccessary for me to be
considered for the gastric bypass surgery.
Believe it or not Aetna was satisfied with this! I was approved after 3
weeks & on the first try!!! Good luck to you!
— Carole M.
January 5, 2003
Hi Helen, I have Aetna PPO and was denied with my first attempt for not
enough medically supervised diet history. What I found out was that Aetna
wants details within the last 2 years of a medically supervised diet of at
least 6 months long. This can simply mean a Dr monitored your weight for
at least six months or joining a program with a medical fast or any other
substance (i.e. Meridia) My PCP has been on me about my weight since 92.
So what we did was have her write a letter explaining each and every diet I
have tried weight loss, weight gain, and a Y/N box for whether it was
medically supervised or not. This was enough for them to approve on the
first appeal. Good luck!
— bevon9602
January 5, 2003
Hi Helen,
I have Aetna insurance and had to document the medically supervised diet.
They want to see that you have tried a diet under the supervision of a
doctor. The Phen/Phen is considered a medically supervised diet and any
diet that your PCP has recommended and supervised (i.e sending you to a
dietitian for a 1200 calorie diet, etc.). I had been sent to see the
dietitian by my doctor and he wrote a letter that I had failed at weight
loss through this way and that he felt WLS was the only option for me. I
also sent my Phen/phen records with the insurance approval letter. They
basically want to see that you have tried other medically supervised diets
and failed at weight loss with them. Hope this helps. Good Luck to you!
Lisa
— Lisa C.
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