FAQ

What insurance will pay for weight loss surgery

aetna covers most weight-loss surgeries. however, you should be aware that most aetna hmo and qpos plans exclude coverage for surgical operations for the treatment of obesity, unless approved by aetna. be sure to contact aetna directly to find out if your policy includes coverage for weight-loss surgery.

aetna prior approval requirements

To qualify for weight loss surgery and be covered by Aetna, you must meet the following criteria.

Reading: What insurance will pay for weight loss surgery

for adults 18 years and older, presence of severe obesity that has persisted for at least the past 2 years (24 months), documented in contemporary clinical records, defined as any of the following:

  1. body mass index (bmi) (see appendix) greater than 40; or
  2. bmi greater than 35 along with any of the following serious comorbidities:
    1. clinically significant obstructive sleep apnea (i.e., individual meets criteria for treatment of obstructive sleep apnea established in cpb 0004 – obstructive sleep apnea in adults); or
    2. coronary heart disease; or
    3. medically refractory hypertension (blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic despite the simultaneous use of 3 antihypertensive agents of different classes); or
    4. type 2 diabetes mellitus
    5. for adolescents who have completed bone growth (generally 13 years in girls and 15 years in boys), presence of obesity with serious comorbidities:

      BMI greater than 40 with one or more of the following serious comorbidities:

      1. clinically significant obstructive sleep apnea; or
      2. type 2 diabetes mellitus; or
      3. pseudotumor comorbidities
      4. See also: What are the principal types of life insurance? | III

        BMI greater than 50 with one or more of the following less severe comorbidities:

        1. medically refractory hypertension; or
        2. hypertension; or
        3. dyslipidemias; or
        4. non-alcoholic steatohepatitis; or
        5. venous stasis disease; or
        6. significant impairment in activities of daily living; or
        7. intertriginous soft tissue infections; or
        8. stress urinary incontinence; or
        9. gastroesophageal reflux disease; or
        10. weight-related arthropathies that affect physical activity; or
        11. psychosocial distress related to obesity.
          • member has attempted weight loss in the past without successful long-term weight reduction; and
          • member must meet criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparative regimen):
          • Physician-Supervised Nutrition and Exercise Program: Member has participated in a physician-supervised nutrition and exercise program (including consultation with a dietician, low-calorie diet, increased physical activity, and behavior modification ), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

            • The member’s participation in a physician-supervised exercise and nutrition 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 preparation regimen, and participation in the nutrition and exercise program may be supervised by the surgeon performing the surgery or by another physician. note: a doctor’s summary letter is not sufficient documentation. documentation must include medical records of the physician’s contemporaneous assessment of the patient’s progress through the nutrition and exercise program. For members participating in a physician-administered nutrition and exercise program (eg, Medifast, Optifast), program records documenting the member’s participation and progress may be substituted for the physician’s medical records; and
            • The 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
            • Nutrition and exercise programs must have a total cumulative duration of 6 months (180 days) or more and occur within 2 years prior to surgery, with participation in a program for at least 3 consecutive months. (Pre-certification may be completed prior to completion of the nutrition and exercise program, provided a cumulative 6-month participation in the nutrition and exercise program(s) is completed prior to the date of surgery).
            • or

CATEGORY: FAQ

Related Articles

Leave a Reply

Your email address will not be published. Required fields are marked *

Back to top button