Aetna and Blue Shield 6 month Diet Requirement Changes

May 15, 2015 3:16 pm

The following  is an update from a previous blog regarding some insurance coverage changes effective date January 2015.  We are required to comply with the insurance diet requirements. This is not an inclusive list of requirement.  Always reference your policies specific requirements. Aetna: 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 at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

1.  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. Records must document compliance with the program; the member must not have a net gain in weight during the program. 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; and
2. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
3. Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)

Blue Shield · Documentation of active participation in a non-surgical weight reduction program supervised by a registered dietician, healthcare provider (e.g., physician, nurse practitioner), or an organized weight reduction program (e.g., Weight Watchers™, Jenny Craig™), for at least six consecutive months occurring within the last 18 months prior to the request for bariatric surgery · Monthly documentation of all of the following weight reduction program components: -Weight -Dietary regimen, which may include medical nutrition therapy (e.g., MediFast™ and OptiFast™) or a recognized commercial diet-based weight loss program (e.g., Weight Watchers™, Jenny Craig™, etc) -Physical exercise unless medically contraindicated -Behavior modification or behavioral health interventions