[NFaith2Lose]

I've never been on a supervised diet and this is the first time I will have visited a doc with a BMI of 40. So, I know that I must began to document/document. Haven't be diagnosed with anything yet - but, will be asking for sleep apnea test.
By reading this... does anyone think I have a chance at approval?

Aetna Open Access HMO / Selection criteria:
1. Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:
a. Body mass index (BMI)* exceeding 40; or
b. BMI* greater than 35 in conjunction with any of the following severe co-morbidities:
i. Coronary heart disease; or
ii. Type 2 diabetes mellitus; or
iii. 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
iv. 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 a (physician-supervised nutrition and exercise program) or criterion b (multidisciplinary surgical preparatory regimen):
a. 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. This physician-supervised nutrition and exercise program must meet all of the following criteria:
i. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
ii. 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
iii. 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
b. 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:
II.Consultation with a dietician or nutritionist; and
III.Reduced-calorie diet program supervised by dietician or nutritionist; and
IV.Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to
surgery, supervised by exercise therapist or other qualified professional; and
V.Behavior modification program supervised by qualified professional; and
VI.Documentation in the medical record of the member's participation in the
multidisciplinary surgical preparatory regimen. (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.)

[DocSanae]

First, welcome to the board, thank you for joining us.

The criteria is in accordance with the guideline set up by NIH for weighloss surgery.
You need a record of past unsuccessful attempts at losing weight the conventional way. Does your dr have records of your weight for 5 years or more? Has your dr ever recommended that you should lose weight? These are some of the things you can start with.
Even if you are not aware of it, with a complete physical check up, you may find some data that fit the criteria.
Anyway, the best thing to do is to go to introductory sessions for prospective surgery patients, and work with your PCP in documenting your needs.
At least, with a BMI over 40 with no comorbidities, you do have a chance for approval, but there are many surgeons who set up their own criteria added to the NIH guidline, so you need to do research on both sides, the surgeon and your insurance.
Have you checked out the Insurance eBook written by CraigT the Guru of this site? It will probably give you some good info on what you need to do.

((((((HUGS))))) May your journey go well.

[MsVickie]

Hi im Vickie. Did you ever find out anything?