Aetna – Requirements for Weight Loss Surgery

Aetna covers most weight loss surgeries. However, you should note that most Aetna HMO and QPOS plans exclude coverage of surgical operations for the treatment of obesity unless approved by Aetna. Make sure you contact Aetna directly to find out if you policy includes weight loss surgery coverage.

Aetna Pre-approval requirements

To qualify for weight loss surgery and have it covered by Aetna you must meet the criteria below.

For adults aged 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), documented in contemporaneous clinical records, defined as any of the following:

1. Body mass index (BMI) (see appendix) exceeding 40; or
2. BMI greater than 35 in conjunction with any of the following severe comorbidities:
   1. Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth 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 concurrent use of 3 anti-hypertensive agents of different classes); or
   4. Type 2 diabetes mellitus

   For adolescents who have completed bone growth (generally age of 13 in girls and age of 15 in boys), presence of obesity with severe comorbidities:

   BMI exceeding 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

   BMI exceeding 50 with one or more of the following less serious comorbidities:

   1. Medically refractory hypertension; or
   2. Hypertension; or
   3. Dyslipidemias; or
   4. Nonalcoholic 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 impair physical activity; or
   11. Obesity-related psychosocial distress.
   • Member has attempted weight loss in the past without successful long-term weight reduction; and
   • Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen):

   Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietitian 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:

   • 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. 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
   • Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dietitians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
   • 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. (Pre-certification 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.)
   • Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) duration meeting 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 post-operative medical care and dietary restrictions:
   • Behavior modification program supervised by qualified professional; and
   • Consultation with a dietitian or nutritionist; and
   • Documentation in the medical record of the member’s participation in the multi-disciplinary surgical preparatory regimen at each visit. (A physician’s summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician’s initial assessment of the member, and the physician’s assessment of the member’s progress at the completion of the multi-disciplinary surgical preparatory regimen.); and
   • Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
   • Program must have a substantial face-to-face component (must not be entirely delivered remotely); and
   • Reduced-calorie diet program supervised by dietitian or nutritionist.

   For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre and post-operative regimen.

   Note:

   The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

   Types of weight loss surgeries covered by Aetna

   • Lap or open Gastric Bypass (Roux-en-y)
   • Lap Gastric Bands – Realize or Lap Band
   • Lap Gastric Sleeve – Sleeve Gastrectomy
   • Duodenal Switch

   Unsure of which procedure is right for you? Take our bariatric surgery selector test.

   Procedures excluded from coverage

   The following procedures are not covered by Aetna:

   • Bariatric surgery as a treatment for idiopathic intracranial hypertension
   • Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty)
   • Intragastric balloon
   • Laparoscopic gastric plication
   • LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above
   • Loop gastric bypass
   • Mini gastric bypass
   • Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons
   • Silastic ring vertical gastric bypass (Fobi pouch)Transoral endoscopic surgery (e.g., the StomaphyX device/procedure)
   • VBG, except in limited circumstances noted above.

   Does Aetna Require Center of Excellence?

   Aetna currently does not specify that obesity surgery must occur at a Center of Excellence accredited institution.

   Do I have to use an In-Network Bariatric Surgeon?

   This will depend on your policy. The use of an in-network provider may reduce your out-of-pocket expenses.

   Aetna Contact Info to Inquire About Surgery

   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’s Weight Loss Surgery Full Coverage Statement

   Aetna’s Clinical Policy relating to weight loss surgery is found here.