Aetna Requirement for Bariatric Surgery

Aetna Requirement for WLS

Aetna covers most types of weight loss surgery, but because differences can exist from policy to policy, you need to check your individual policy for specifics. For example, most Aetna HMO plans and Aetna QPOS plans will exclude coverage for obesity-related surgical procedures unless Aetna improves the surgery individually. It will be important for you to contact Aetna directly so that you can determine whether or not your individual policy covers the weight loss surgery you want to have.

Requirements for Pre-Approval from Aetna

Aetna has coverage requirements for adults and adolescents. For adults who are aged 18 years and older, you need to be categorized as severely obese for at least 24 months and this obesity needs to be documented well by your physicians. According to Aetna, severe obesity is defined as:

• Body Mass Index (BMI) of 40 or greater, or
• Body Mass Index (BMI) of 35 or greater when paired with severe comorbidity.
• Comorbidities can include obstructive sleep apnea, coronary heart disease, medically refractory hypertension or type 2 diabetes.

For adolescents:

• You have to have completed your bone growth which means that you are 13 years or older and female, or 15 years or older and male,
• Body Mass Index of 40 or higher paired with one of the aforementioned serious comorbidities, or pseudotumor comorbidities, or
• Body Mass Index of 50 or higher with less serious comorbidity, such as:

• Medically refractory hypertension,
• Hypertension,
• Nonalcoholic steatohepatitis,
• Venous stasis disease,
• Dyslipidemias,
• Significant activity impairments,
• Stress urinary incontinence,
• Intertriginous soft-tissue infection,
• Arthropathies related to weight,
• Gastroesophageal reflux disease (GERD)
• Weight-related psychosocial stress.

Additionally:

• Both adult and adolescent patients need to have evidence of attempted weight loss in the past without any long-term reduction in weight.
• The patient will also need to undergo either physician-supervised nutrition and exercise program or a multi-disciplinary surgical preparatory plan to determine fitness for the surgical procedure. This must be well documented by the patient’s physician(s) in order to determine whether or not surgery is the next best option. Aetna has some very specific requirements for how this is done, and you need to document things exactly how Aetna wants them done in order to qualify for coverage of your weight loss surgery. As such, you will want to make sure that you consult your insurance provider for a full understanding of what this requirement entails.

Surgeries Aetna Covers for Weight Loss

• Gastric bypass (either laparoscopic or open)
• Gastric banding (Lap-Band or Realize Band)
• Gastric sleeve (Laparoscopic)
• Duodenal switch

Surgeries Aetna Doesn’t Cover for Weight Loss

The following medical procedures are not currently covered by Aetna:

• Bariatric surgery to treat idiopathic intracranial hypertension,
• Gastroplasty (stomach stapling)
• Intragastric balloon,
• Gastric plication (Laparoscopic)
• Procedures for patients who do not meet the above criteria for approval,
• Loop gastric bypass,
• ‘Mini’ gastric bypass,
• Roux-en-Y gastric bypass for patients who are non-obese,
• Silastic ring vertical gastric bypass,
• VBG, except with some limited circumstances.

Additional Requirements

Some Aetna policies will require that you use an in-network provider for your weight loss surgery, but this is not always the case. Using an in-network provider will generally reduce the out-of-pocket expenses that you need to pay. Your individual insurance policy will help guide you to find the right provider for this procedure, so make sure that you contact Aetna to determine the best place to undergo your weight loss surgery for the best results and a good price.