Aetna Weight Loss Surgery - How to Avoid a Denial

Your Aetna weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

First, try our insurance tool to quickly check your insurance coverage:

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List of Aetna Insurance Company Partners

Aetna’s policy on weight loss also apply to their partners, including:

Read and click below for additional weight loss surgery insurance details.

TABLE OF CONTENTS

  1. Coverage Requirements
  2. Coverage by Plan Type
  3. Covered Weight Loss Procedures
  4. Appealing a Denial
  5. Find a Top Weight Loss Surgeon
1.

Coverage Requirements

  • 35+ Body Mass Index (BMI)

  • Documentation of failed diet attempts

  • Psychological evaluation

Aetna Weight Loss Surgery

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policiy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Aetna for bariatric surgery in the United States, you must meet the following criteria:

For adults aged 18 years or older

  • Diagnosis of Morbid obesity, defined as
  • Or

    • BMI 35 – 39.9 AND one of the following
      • Clinically significant obstructive sleep apnea
      • Coronary heart disease
      • Medically refractory hypertension
      • Type 2 diabetes mellitus

Use this BMI Calculator to check your body mass index…

BMI Calculator

Enter your height and weight, then click the button.

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Your BMI35.7Severely Obese
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Does your BMI qualify you for a weight loss procedure?

Yes!

For adolescents: defined as those who have completed bone growth. (generally age of 13 in girls and age of 15 in boys)

  1. Diagnosis of Morbid obesity, defined as
    • BMI exceeding 40 AND one of the following
      • Clinically significant obstructive sleep apnea
      • Type 2 diabetes mellitus
      • Pseudotumor comorbidities

      Or

    • BMI exceeding 50 and one of the following
      • Medically refractory hypertension
      • Dyslipidemias
      • Nonalcoholic steatohepatitis
      • Venous stasis disease
      • Significant impairment in activities of daily living
      • Intertriginous soft-tissue infections
      • Stress urinary incontinence
      • Gastroesophageal reflux disease
      • Weight-related arthropathies that impair physical activity
      • Obesity-related psychosocial distress
  2. Member has attempted weight loss in the past without successful long-term weight reduction
  3. Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen)

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Lab work
  • Medically supervised diet program
  • Psychological exam
  • Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Aetna Contact Information and Full Medical Policy on Bariatric Surgery

2.

Coverage by Plan Type

  • Coverage Through Your Employer

  • Individual & Family Plans

  • Medicare

Aetna Weight Loss Surgery

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

Aetna does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Aetna plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

    • Arizona
    • California
    • Delaware
    • Hawaii
    • Illinois
    • Iowa
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Oklahoma
    • Rhode Island
    • South Dakota
    • Vermont
    • West Virginia
    • Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

3.

Covered Weight Loss Procedures

  • Gastric Sleeve

  • Gastric Bypass

  • Lap-Band

  • Duodenal Switch

  • Biliopancreatic Diversion

Aetna Weight Loss Surgery

Please see below for the procedures Aetna covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by Aetna:

Procedures That Are NOT Covered

The following procedures are NOT covered by Aetna:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Mini Gastric Bypass Surgery
  • “Band over bypass” or LASGB revision of prior Roux-en-Y gastric bypass
  • “Band over sleeve” or LASGB revision of prior sleeve gastrectomy
  • Bariatric surgery as a treatment for infertility
  • Bariatric surgery as a treatment for type-2 diabetes in persons with a BMI less than 35
  • Gastric bypass as a treatment for gastroparesis
  • Laparoscopic gastric plication (also known as laparoscopic greater curvature plication [LGCP]), with or without gastric banding
  • Liposuction (suction-assisted lipectomy; ultrasonic assisted liposuction)
  • Loop gastric bypass
  • Natural orifice transoral endoscopic surgery
  • Open adjustable gastric banding
  • Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons
  • Sclerotherapy for the treatment of dilated gastrojejunostomy following bariatric surgery
  • Silastic ring vertical gastric bypass (Fobi pouch)
4.

Appealing a Denial

  • General Appeal Instructions

  • Appeal Details Specific to Aetna

Aetna Weight Loss Surgery

If Aetna denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Aetna to learn how to proceed.

5.

Find A Top Weight Loss Surgeon

  • Ask for a free insurance check or cost quote

  • Attend a free seminar or webinar

  • Schedule a phone or in-person consultation (both often free)

Search the weight loss surgeon directory below to ask a top surgeon about a free insurance check by country and region: