Aetna and Cigna Criteria

Congratulations!! You have made the decision to undergo weight loss surgery. Surgical interventions provide an effective option for the morbidly obese who have tried all other venues, such as diet, exercise and pharmacotherapy. It is important that you realize the substantial amount of time required for the surgical evaluation and preparation for surgery. We realize that the wait is difficult and we will do our utmost to minimize the time it takes.

CONCERNING AETNA AND CIGNA:

Both insurance companies require additional criteria, which may delay the approval of your procedure. (For details, please see the attached medical policies from these insurances.) These are their policies and we have no choice but to comply.

Although this is very frustrating both to you as our patient and us as a provider, there are positive outcomes through compliance.

Any weight loss could improve your health.
As well as any exercise could improve your health.
Any nutritional knowledge gained could help you understand your body’s nutritional requirements.

The information on the following page is to be used by you and your primary physician to facilitate and maximize your likelihood of a speedy and uncontested insurance approval. Since the criteria involves at least a six (6) month time period, we recommend you begin this process as soon as possible.

****Important information that is now required for pre-approval for Bariatric surgery through Aetna and Cigna: Cigna requires documentation of TWO (2), six (6) months’ duration, physician supervised, weight loss attempts. And Aetna requires One (1) such program. Without this information, the approval process is impossible and will almost certainly be delayed up to 1 year! If the following information is not available, denials or delays always follow.

HERE IS HOW TO BEST COMPLY AND HELP US WITH THE PRE-APPROVAL PROCESS. BEGIN THIS AS SOON AS POSSIBLE:

Go to your primary physician’s office and get weighed and make sure that they document your weight in your chart. Both Aetna and Cigna required documented weights for the previous five (5) years. Presence of morbid obesity that has persisted for at least 5 years.
Have your physician recommend an exercise and /or diet regimen and document this recommendation in your chart. (Aetna needs documentation with the following: (a.) Participation in nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; AND (b.) Nutrition and exercise program must be 6 months or longer in duration; AND (c.) Nutrition and exercise program must occur within the two years prior to surgery. NOTE: A physician summary letter is not sufficient documentation. (Cigna: Active participation in monthly weigh-ins from two six (6) month professionally supervised weight loss programs (diets and exercise) with the past two years.
Go back to your physician’s office at least every 4 weeks and weigh-in. Have them document your weight. Make sure this is recorded in your chart. At these evaluations, also have your physician note your progress and make recommendations as to how to proceed with improving your progress. DOCUMENTATION IS CRITICAL!!! A full note must be written noting your progress and the recommendations given.
If the diet and/or exercise regimen is not effectively helping you lose weight, go see your physician again and have him/her recommend an alternative program.
CONTINUE THE WEIGH-INS.
If you have Cigna, after 6 months, go in and have your physician recommend an alternative regimen and, once again, document the whole process on a monthly basis.
Have copies of this record available when you come in to the Bariatric Office.
If your physician has questions or concerns about this plan, please have him/her contact Dr. Bruce Applebaum or Dr. Manuel Castro-Arreola directly.

***If this information is in hand at your consult with the Bariatric nurses, the approval process (if you qualify for surgery) is usually quite easy. We will make every effort to expedite the process for you at this point.

HOW THIS IS OFTEN DONE:
(Note: specific diets mentioned are for the purposes of illustration only. They are not meant to be a guide for or suggestion of treatment options.)

For example, it would be great to have your physician recommend Jenny Craig for 6 months then The Zone for 6 months. Have him/her record the recommendations and your agreement to try them. DOCUMENTATION AT EVERY ENCOUNTER IS CRITICAL!! This will need to be available to present to your insurer. The more detailed the better.
Make sure that there are visits during the interval of each diet regimen and exercise regimen and WEIGHTS RECORDED---monthly at least.
Then, make sure when you change to the new diet he/she records, for example: “Patient compliant with Jenny Craig diet for past 6 months and weight loss of XXXX. Inadequate weight loss/failure with this plan noted. Will attempt The Zone Diet starting today.”
Then continue the process for the second diet. For six (6) months at least.
This is not a recipe for failure, although, we must note the following:
You may lose some weight, but it has been proven that for morbidly obese individual the “success” of traditional weight loss regimens is less than 5%. ALL OF YOU HAVE EXPERIENCED THIS FIRST HAND ALREADY.

We hope that this information will prevent the delays in the pre-approval process and the denials we have unfortunately seen in the past with Cigna and Aetna. Please call if you should have any question: (915) 577-7570. We appreciate your help.