Aetna covers bariatric surgery for patients meeting certain eligibility requirements. Because individual plans and employer-sponsored policies can vary, you’ll need definitive verification through your insurance carrier to confirm coverage details and exclusions, but this information can help get you started.
For Floridians interested in bariatric surgery, Aetna members who meet medical necessity requirements outlined in their clinical policy guidelines might have coverage. How much coverage varies depending on your individual plan, employer-sponsored benefits, and policy exclusions, so it’s important to verify your benefits directly with your insurance carrier before beginning the process. Even though every plan is different, getting to know Aetna’s general bariatric surgery criteria with the help of MIIS Weight Loss Institute is a great place to begin.
Which Procedures Are Covered?
Covered primary procedures we offer at MIIS include gastric bypass (Roux-en-Y) and sleeve gastrectomy. Aetna’s policy also recognizes coverage for revision surgery when it is deemed medically necessary due to complications, anatomical problems, device failure, severe reflux (GERD), or inadequate weight loss following a prior bariatric procedure.
Because covered services can change as policies are updated, it’s always best to confirm coverage for a specific procedure with your insurer directly.
What Are the Eligibility Requirements?
For primary bariatric surgery, Aetna requires patients to meet BMI-based medical necessity criteria:
- A BMI of 40 or greater (or 37.5 for patients of Asian descent), or
- A BMI of 35 or greater (or 32.5 for patients of Asian descent) with at least one serious obesity-related condition, such as type 2 diabetes, obstructive sleep apnea, hypertension, coronary artery disease, or nonalcoholic steatohepatitis.
Patients are usually required to complete nutritional, medical, and psychological assessments before surgery to help determine whether bariatric surgery is an appropriate and safe treatment option. Proof of previous medically-assisted weight loss attempts and obesity-related health conditions may also be required during the authorization process.
If you’re wondering whether revision surgery is covered, it often is. Insurance companies will want documentation to establish medical necessity, including records of the prior surgery, rationale for the revision, imaging studies, and other relevant medical information. Gastric band complications, Candy cane syndrome, otherwise untreatable gastroesophageal reflux disease (GERD), inadequate weight loss despite adherence to protocols, or failure of the previous procedure (like staple-line issues or gastric pouch dilation) are some of the reasons Aetna will approve revision surgery.
What Else is Helpful to Know?
Aetna policies may require bariatric surgery to be performed at approved facilities or by qualified providers meeting their credentialing standards. Depending on your plan, surgery may need to take place within a designated network or accredited bariatric program to qualify for coverage.
Even when surgery is approved, out-of-pocket (OOP) costs, like deductibles, copays, coinsurance, and annual out-of-pocket maximums, can still apply depending on your specific plan. Since OOP expenses vary, be sure to ask your insurer for a detailed explanation regarding your financial responsibility early on. You don’t want to be surprised by an unexpected bill.
Preauthorization requests can sometimes be denied, and if that happens, don’t worry. It could just be a clerical error or missing information. Patients have the right to appeal the decision and submit additional medical records, physician documentation, or other supporting information for reconsideration. For that reason, it’s a good idea to keep organized records of doctor visits, previous weight loss treatments, referrals, testing, and any communication with your insurance company. Doing so along the way will make the process smoother and bolster your case for approval.
Understanding insurance coverage can be overwhelming, especially when requirements differ from one plan to another. If you need help verifying your benefits or understanding your options, the team at MIIS Weight Loss Institute can help guide you through the process and answer questions along the way.
Note: This information does not take the place of your particular policy benefits or any Aetna definitions of care or coverage.
