For individuals considering weight loss surgery, understanding health insurance coverage is a critical first step. Aetna, a leading insurance provider, offers a variety of plans that may cover bariatric surgery when deemed medically necessary. This article explores Aetna's coverage policies, eligibility requirements, covered and non-covered procedures, and steps to take when seeking approval.
Aetna's Coverage Overview for Weight Loss Surgery
Aetna generally covers a range of bariatric surgeries, recognizing that individuals may require different procedures based on their unique health conditions and weight loss goals. However, coverage details may vary depending on the specific plan. Some Aetna plans may exclude coverage of surgical operations for the treatment of obesity unless approved by Aetna. It's important to note that some Aetna benefit plans specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion.
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.
Whether you’re enrolled in an employer-sponsored plan, an individual policy, or through the healthcare marketplace, Aetna provides various plan levels. Yes - Aetna may cover bariatric surgery for eligible members when specific medical criteria are met. These qualifications include: a body mass index (BMI) of 40 or higher; a BMI of 35 or higher with obesity-related health conditions like type 2 diabetes, hypertension, cardiac issues, or sleep apnea, to name a few; documented evidence of participation in a physician-supervised weight management program; psychological evaluation; and nutritional counseling.
Eligibility Requirements for Aetna Coverage
Aetna has specific criteria that members must meet to be eligible for weight loss surgery coverage. These requirements differ slightly for adults and adolescents:
Read also: Does Aetna Cover Weight Loss Drugs?
Adults
- Age: 18 years of age or older.
- Duration of Obesity: Must have been considered severely obese for two years (or 24 months), which has been clinically documented.
- Body Mass Index (BMI):
- A BMI of 40 or more.
- A BMI of more than 35 along with any of the following health conditions:
- Substantial obstructive sleep apnea
- Coronary heart disease
- Medically refractory high blood pressure (140/90 even with using 3 different high blood pressure medications)
- Type 2 diabetes mellitus
Adolescents
- Age and Bone Growth: Teenagers who have completed their bone growth (age 15 for boys; 13 for girls) are eligible so long as their obesity comes with serious co-conditions.
- BMI and Comorbidities:
- A 40+ BMI with any three co-conditions:
- Type 2 diabetes mellitus
- Serious obstructive sleep apnea
- Psedotumor comorbidities
- A 50+ BMI with one or more of the less serious co-conditions:
- Hypertension or medically refractory hypertension
- Nonalcoholic steatohepatitis
- Dyslipidemias
- Serious impairment of daily living
- Venous stasis disease
- Stress urinary incontinence
- Intertriginous soft-tissue infections
- Serious impairment of daily living activities
- Gastroesophageal reflux disease
- Psychosocial distress due to obesity
- Arthropathies due to weight
- A 40+ BMI with any three co-conditions:
Additional Requirements for All Eligible Members
Documented Weight Loss Attempts: Members who have tried to lose weight in the past but have not successfully had a loss in weight. Members will need to meet either criterion one or two.
Pre-Surgical Program Participation: Participation in a food and exercise program has been doctor-documented in the person’s medical records. An exercise and food program may be given as one part of the before surgical regimen and participation may be surgeon-supervised. A summary letter from a physician does not qualify as satisfactory documentation.
- Program Documentation:
- Doctor’s medical records, noting the progress of the patient throughout the exercise and food program. Patients involved in a physician-given exercise and food program, records that reflect their participation and progress can be an alternative to a doctor’s medical records. A physician will work in correlation with nutritionists and dieticians in the exercise and food program.
- The program must have been used concurrently for six months or more and take place within two years before the surgery with membership in one program for three months. You may be able to certify before you finish the food and exercise program so long as participation in the program has been going on for six months and is done before the surgery date.
- OR Multi-disciplinary preliminary regimen for surgery: Within six months of the surgery, the patient must be partaking in a structured multidisciplinary preliminary regimen for surgery for three months, making sure to follow all the criteria to boost the surgical outcome, lessen the possible complications and establish their ability to deal with and follow all dietary restrictions and post-operative medical care.
- Supervision of behavior modification program by a doctor.
- Dietician consultation.
- Documentation of the participation in the medical records at every visit. A summary letter from the doctor is not enough for documentation. Rather, the documentation needs to include:
- Medical records of doctor’s initial assessment and doctor’s assessment after completion of the regimen.
- Exercise program to improve the pulmonary reserve before surgery and be supervised by a qualified professional or exercise therapist.
- Program must have been done face to face, not remotely.
- A supervised nutritionist diet programs that is reduced in calories.
- Program Documentation:
Psychological Evaluation: For people who have a history of psychiatric disturbances - borderline personality disorder, schizophrenia, severe depression, etc., 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.
Intensive Behavioral Intervention: Member has participated in an intensive multicomponent behavioral intervention designed to help participants achieve or maintain weight loss through a combination of dietary changes and increased physical activity.
- Member's participation in an intensive multicomponent behavioral intervention must be documented in the medical record. Records must document compliance with the program.
- For members who participate in an intensive multicomponent behavioral intervention (e.g., Jenny Craig, MediFast, Minute Clinic/Health Hubs, OptiFast, Weight Watchers), program records documenting the member's participation and progress may substitute for medical records.
Bariatric Procedures Covered by Aetna
Aetna offers coverage for several types of weight loss surgeries, including:
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- 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.
Procedures Generally Not Covered by Aetna
Certain procedures are typically not covered by Aetna, including:
- Bariatric Surgery for Idiopathic Intracranial Hypertension
- Gastroplasty (Stomach Stapling)
- Intragastric Balloon
- 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
The Approval Process for Bariatric Surgery with Aetna
Navigating the approval process for bariatric surgery with Aetna involves several steps:
- Understand Your Insurance Policy: The first and most crucial step is reviewing your Aetna insurance policy documents thoroughly. While you can review your insurance policy package to see what weight control expenses are covered or excluded, you may find it easier to simply give us a call, or text us now at (855) 690-0565 to verify your insurance details. There is absolutely no obligation to have us verify your gastric sleeve coverage and if you don’t meet your insurance policy’s criteria, we can request an individual need assessment, or send a letter of medical necessity on your behalf.
- Verify Eligibility: Contact Aetna directly to verify your eligibility for bariatric surgery coverage. 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.
- Consult with Your Healthcare Team: Schedule consultations with your healthcare team, including your primary care physician and a qualified bariatric surgeon.
- Follow Aetna’s Requirements: Aetna may have specific requirements for coverage approval, such as evidence of previous weight loss attempts, documentation of co-morbidities related to obesity, or participation in a medically supervised weight loss program.
- 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. 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.
- 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.
- 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.
- 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. 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.
- Submit Necessary Documentation: Prepare and submit all required documentation, including medical records, physician recommendations, and any other information specified by Aetna. This documentation could include medical history and physical exam notes, lab and imaging results, evidence of previous weight loss efforts, and letters of medical necessity from your healthcare providers.
- Prior Authorization: Many surgical procedures require prior authorization from Aetna. This means your surgeon must submit medical documentation proving that the procedure is medically necessary; it helps to ensure that the surgery is appropriate and covered under your plan.
- Important note: Failing to obtain prior authorization could result in claim denial or increased out-of-pocket costs so be sure not to skip this step.
- Appeal if Necessary: In some cases, coverage may be initially denied. If this occurs, keep hope.
- Before pursuing an appeal, contact Aetna to determine the reason for the denial and if an easy fix is available. The next step is to involve your bariatric practice. They have years of experience and expertise to help you navigate an Aetna claim denial. A claim denial is not the end of your journey.
Potential Out-of-Pocket Costs
Even with Aetna coverage, you’ll likely be responsible for part of the cost, depending on your specific plan. Some expenses you’ll need to consider include meeting your deductible, paying a copay or coinsurance, and out-of-network provider or facility penalties. This information should be outlined in your “Explanation or Benefits” (EOB) section of your insurance plan.
Every health insurance policy has some out-of-pocket costs for the member and Aetna is no exception.
- Deductibles: Your plan deductible is an amount specified in your plan that resets each year. You likely have an individual and a family deductible.
- Co-Insurance: Before meeting your deductible your plan may require co-insurance for certain tests and procedures. Once you’ve met or paid your deductible, there will still be co-insurance expenses. This means you will share the cost of many of your medical services with Aetna on a percentage basis. While Aetna will usually cover the larger percentage, knowing what percentage you are responsible for and being prepared will prevent any undue stress.
- Out-of-pocket costs for Gastric Bypass typically range from $5,000-8,000.
Choosing In-Network Providers
You have the freedom of choice when it comes to your doctors, facilities, and other medical decisions. However, there are some benefits to choosing medical providers within Aetna’s network. Some Aetna policies may necessitate using an in-network provider for your weight loss surgery. This often helps reduce out-of-pocket costs. Your individual insurance policy will provide specific guidance on the right provider for your procedure.
Read also: Aetna Healthy Benefits Guide
Weight Reduction Medications
Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m2Footnotes**). Note: Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan. The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control.
Weight reduction medications should be used as an adjunct to caloric restriction, exercise, and behavioral modification, when these measures alone have not resulted in adequate weight loss. Weight loss due to weight reduction medication use is generally temporary. In addition, the potential for development of physical dependence and addiction is high. Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity.
Tests with weight loss drugs have shown that initial responders tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. If a person does not lose 2 kg (4.4 lbs) in the first four weeks after initiating therapy, the likelihood of long-term response is very low.
Specific Weight Reduction Medications
- Didrex (benzphetamine hydrochloride): Indicated in the management of exogenous obesity as a short term (a few weeks) adjunct in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone. Contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to sympathomimetic amines, and glaucoma.
- Contrave (naltrexone and bupropion): Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
- Orlistat (Xenical, Alli): Indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced‐calorie diet. It is also indicated to reduce the risk for weight regain after prior weight loss. Orlistat is available as Xenical in 120mg capsules and as Alli in 60mg capsules. Alli is available over‐the‐counter.
- Qsymia (phentermine and topiramate): Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia.
- Belviq (lorcaserin): Was approved in June 2012 by the FDA as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related co-morbid condition, and was launched in the United States in June 2013, but was later recalled by the FDA in February 2020 due to safety concerns.
- Saxenda (liraglutide): A once-daily injection of a glucagon-like peptide-1 (GLP-1) receptor agonist, for chronic weight management. The FDA approved labeling states that patients using liraglutide should be evaluated after 16 weeks to determine if the treatment is working.
The Importance of a Multidisciplinary Approach
The American College of Surgeons (ACS) has stated that the surgeon performing the bariatric surgery be committed to the multidisciplinary management of the patient, both before and after surgery. The ACS recommended: "They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, diabetology, psychiatry, and rehabilitation medicine.
A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature to to provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multi-disciplinary care required to minimize peri-operative and post-operative risks in patients with severe obesity who undergo weight loss surgery. The Task Group recommended multi-disciplinary screening of weight loss surgery patients to ensure appropriate selection; pre-operative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; pre-operative weight loss and cessation of smoking; peri-operative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); pre-operative and post-operative education and counseling by a registered dietitian; and a well-defined post-surgical diet progression.