Aetna – Requirements for Weight Loss Surgery

Filling out an insurance claim form.

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.

Virtual Bariatric Surgery Support Group May 2024

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.

    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:

    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

    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:

    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.