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Aetna Bariatric Surgery Requirements

Aetna Bariatric Surgery Requirements

To determine if your Aetna Health Insurance Plan covers weight loss surgery, you’ll need to check the specifics of your individual policy, as coverage can vary. While most types of weight loss surgeries are generally covered by Aetna, there can be differences based on the plan type. For instance, most Aetna HMO plans and Aetna QPOS plans may not cover obesity-related surgical procedures unless the surgery is approved by Aetna on an individual basis.

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It’s crucial for you to contact Aetna directly to confirm whether your specific policy covers the weight loss surgery you are considering. This direct inquiry will provide you with the most accurate and personalized information regarding your coverage options and any necessary requirements or conditions that must be met for the surgery to be approved under your plan.

Requirements for Pre-Approval from Aetna

To receive pre-approval from Aetna for weight loss surgery, there are specific requirements for both adults and adolescents:

For Adults (18 years and older):

Severe Obesity Duration: You must be classified as severely obese for at least 24 months, with this condition well-documented by your physicians.

Body Mass Index (BMI): Severe obesity is defined by Aetna as:

  • A BMI of 40 or greater, or
  • A BMI of 35 or greater, along with serious obesity-related comorbidities like obstructive sleep apnea, coronary heart disease, medically refractory hypertension, or type 2 diabetes.

For Adolescents:

Age and Bone Growth Completion: Females must be 13 years or older, and males 15 years or older.

BMI and Comorbidities:

  • A BMI of 40 or higher with serious comorbidities (such as those listed for adults) or pseudotumor comorbidities, or
  • A BMI of 50 or higher with less serious comorbidities, like medically refractory hypertension, hypertension, nonalcoholic steatohepatitis, venous stasis disease, dyslipidemias, significant activity impairments, stress urinary incontinence, intertriginous soft-tissue infection, arthropathies related to weight, or gastroesophageal reflux disease (GERD), and weight-related psychosocial stress.

Additional Requirements for Both Adults and Adolescents:

Evidence of Prior Weight Loss Attempts: There must be documentation of attempted weight loss in the past without long-term success.

Pre-Surgical Preparatory Program: Patients are required to undergo a physician-supervised nutrition and exercise program or a multi-disciplinary surgical preparatory plan. This program must be well-documented to assess the patient’s fitness for surgery.

It’s important to consult with your insurance provider to fully understand these requirements, as Aetna has specific guidelines for documentation and qualifying criteria. Ensuring that everything is documented precisely as per Aetna’s standards is crucial for coverage approval of the weight loss surgery.

Bariatric Procedures Covered and Not Covered by Aetna

Aetna covers a variety of weight loss surgeries, but also excludes certain procedures. Understanding what is covered and what isn’t can guide you in making informed decisions about your surgical options:

Surgeries Covered by Aetna for Weight Loss:

  • Gastric Bypass: This can be performed either laparoscopically or as an open surgery.
  • Gastric Banding: Including the Lap-Band or Realize Band methods.
  • Gastric Sleeve: Specifically, the laparoscopic version of this surgery.
  • Duodenal Switch: Another surgical option covered under certain Aetna plans.

Surgeries Not Covered by Aetna for Weight Loss:

  • Bariatric Surgery for Idiopathic Intracranial Hypertension
  • Gastroplasty (Stomach Stapling)
  • Intragastric Balloon: This procedure is currently not covered.
  • Gastric Plication (Laparoscopic)
  • Procedures for Patients Not Meeting Approval Criteria: Includes surgeries for those who do not fit the specific requirements outlined by Aetna.
  • Loop Gastric Bypass
  • ‘Mini’ Gastric Bypass
  • Roux-en-Y Gastric Bypass for Non-Obese Patients
  • Silastic Ring Vertical Gastric Bypass
  • VBG (Vertical Banded Gastroplasty): except under limited circumstances

Additional Considerations:

  • In-Network Provider Requirement: Some Aetna policies may necessitate using an in-network provider for your weight loss surgery. This often helps reduce out-of-pocket costs.
  • Policy Guidance: Your individual insurance policy will provide specific guidance on the right provider for your procedure. It’s important to contact Aetna to determine the most suitable and cost-effective option for your weight loss surgery.

Make sure to consult with Aetna directly to understand your policy’s coverage and any specific criteria or requirements that apply to your situation.

2 thoughts on “Aetna Bariatric Surgery Requirements

    1. Contact Aetna directly so that you can determine whether or not your individual policy covers the weight loss surgery you want to have.

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