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.
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:
- body mass index (bmi) (see appendix) greater than 40; or
- bmi greater than 35 along with any of the following serious comorbidities:
- 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
- coronary heart disease; or
- 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
- type 2 diabetes mellitus
- clinically significant obstructive sleep apnea; or
- type 2 diabetes mellitus; or
- pseudotumor comorbidities
- medically refractory hypertension; or
- hypertension; or
- dyslipidemias; or
- non-alcoholic steatohepatitis; or
- venous stasis disease; or
- significant impairment in activities of daily living; or
- intertriginous soft tissue infections; or
- stress urinary incontinence; or
- gastroesophageal reflux disease; or
- weight-related arthropathies that affect physical activity; or
- psychosocial distress related to obesity.
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:
BMI greater than 50 with one or more of the following less severe comorbidities:
- 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):
- 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).
- Multidisciplinary Surgical Preparative Regimen: Close to the time of surgery (within 6 months prior to surgery), the member must participate in an organized Multidisciplinary Surgical Preparative Regimen meeting for at least 3 months (90 days ) duration 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 postoperative medical care and dietary restrictions:
- behavior modification program supervised by a qualified professional; and
- consult with a dietitian or nutritionist; and
- Documentation in the medical record of the member’s participation in the multidisciplinary surgical preparative regimen at each visit. (A physician’s summary letter, without evidence of contemporaneous supervision, is not sufficient documentation. Documentation must include medical records of the physician’s initial evaluation of the member and the physician’s assessment of the member’s progress upon completion of the preparative regimen multidisciplinary surgical. .); and
- Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by a physical therapist or other qualified professional; and
- the program must have a substantial face-to-face component (it must not be delivered entirely remotely); and
- low-calorie diet program supervised by a dietitian or nutritionist.
- open gastric bypass (roux en-y)
- lapped gastric bands – make or lap band
- Lap sleeve gastric – sleeve gastrectomy
- duodenal switch
- bariatric surgery as a treatment for idiopathic intracranial hypertension
- gastroplasty, more commonly known as “stomach stapling” (see below for clarification on vertical banded gastroplasty)
- intragastric balloon
- laparoscopic gastric plication
- lasgb, rygb, and bpd/ds procedures that do not meet the above medical necessity criteria
- loop gastric bypass
- mini-gastric bypass
- en and roux gastric bypass as a treatment for gastroesophageal reflux in non-obese people
- vertical gastric bypass with silastic ring (fobi bag)transoral endoscopic surgery (eg, the stomafix device/procedure)
- vbg, except in the limited circumstances noted above.
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:
for members who have a history of serious psychiatric disorders (schizophrenia, borderline personality disorder, suicidal ideation, major depression) or who are currently under the care of a psychologist/psychiatrist or taking psychotropic medications, preoperative psychological clearance is required to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and post-operative regimen.
The presence of depression due to obesity is not normally considered a contraindication for obesity surgery.
types of weight loss surgeries covered by aetna
Not sure which procedure is right for you? take our bariatric surgery selection test.
procedures excluded from coverage
the following procedures are not covered by aetna:
does aetna require a center of excellence?
Currently, aetna does not specify that obesity surgery must be performed at an institution accredited as a center of excellence.
Do I have to use an in-network bariatric surgeon?
This will depend on your policy. Using an in-network provider can lower your out-of-pocket costs.
aetna contact information for surgery consultation
You can call aetna for member questions at: 1-800-us-aetna (7:00 am – 7:00 pm est). You can also email aetna by going here.
aetna weight loss surgery comprehensive coverage statement
aetna’s clinical policy related to weight loss surgery can be found here.