Does Aetna Cover Bariatric Surgery?

If you are considering improving your health through bariatric surgery, and have an Aetna health insurance plan, there are several pre-approval requirements and out-of-pocket expenses you will want to know upfront for a successful journey to wellness through bariatric surgery.

Aetna Pre-Approval Requirements for Bariatric Surgery

While Aetna covers the most common bariatric, or weight loss, surgeries, there are some Aetna policies (HMO and QPOS plans in particular) that specifically exclude any surgical procedure to treat obesity without pre-approval.

The only way to know for sure what your individual Aetna policy covers and requires is to reference your plan documents or call Aetna directly. However, the following are general Aetna pre-approval requirements for bariatric surgery.

Aetna Eligibility Requirements:

• 18 years of age or older
• Body Mass Index (BMI) of 40 or higher
• BMI of 35 with significant co-morbidities such as high blood pressure, obstructive sleep apnea, Type 2 diabetes, coronary heart disease
• Two years (24 months) of persistent severe obesity documentation
• Documented unsuccessful weight loss attempts in the past.
• Completion of a physician-supervised nutrition and exercise program with six months (180 days) of documentation within two years of surgery or a multi-disciplinary surgical preparatory regimen within six months of surgery.
• Pre-operative psychological clearance for individuals with a substance abuse disorder, history of an eating disorder, or severe psychiatric disturbance, under the care of a psychologist or psychiatrist, or who are on psychotropic medications.
• Aetna may cover bariatric surgery for adolescents who have completed bone growth (generally age 13 for girls and 15 for boys), have a BMI of 40 or higher, and meet the remaining above eligibility.

Types of Bariatric Surgery Covered by Aetna

There are many different types of bariatric surgery to accommodate a range of needs and desired outcomes. Aetna covers the most common types of bariatric surgery for eligible individuals.

Bariatric surgeries generally covered by Aetna include:

• Gastric Bypass
• Adjustable Gastric Band
• Sleeve Gastrectomy
• Duodenal Switch

The above bariatric surgeries encompass two forms: malabsorptive and restrictive surgeries. These procedures remove, redirect, or restrict the flow of food through the stomach, leading to weight loss. Since obesity is a leading contributor to many other health problems, bariatric surgery has many benefits.

While most other weight loss surgeries are excluded by Aetna, some corrective procedures of previous bariatric surgeries may be covered when medically necessary.

What are My Out-of-Pocket Costs with Aetna?

Every health insurance policy has some out-of-pocket costs for the member and Aetna is no exception. Knowing your out-of-pocket costs during the initial planning stages of your bariatric surgery journey will allow more time for financial preparation and prevent any unwanted surprises.

Three primary out-of-pocket bariatric surgery expenses:

• Deductibles: Your plan deductible is an amount specified in your plan that resets each year. You likely have an individual and a family deductible. If you have not met the family deductible before surgery, you’ll be responsible for any remaining portion of your individual 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. Co-insurance does not go toward your deductible but will count toward your maximum out-of-pocket expenses.

Out-of-Network Expenses

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. Providers out-of-network with Aetna may not be covered, generating additional out-of-pocket expenses.

Your overall wellness is a life-long journey. Understanding your out-of-pocket expenses upfront and preparing to meet them will help keep you moving forward with your journey to better health.

How to Appeal an Aetna Claim Denial

Sometimes, despite your best efforts to meet eligibility requirements, your claim is denied. This can be for several reasons and most of them are easily resolved.

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. Lastly, if other attempts have failed, pursue the Aetna appeals process.

To appeal an Aetna denial, prepare the following:

• The reason you disagree with the denial.
• A copy of the denial letter
• The original claim
• Documents that support your position for reconsideration
• The completed appeal form

A claim denial is not the end of your journey. A properly completed appeal could result in a reversal of the denial and put you back on track.

If you are unsure about what type of surgery is covered by your individual plan or any of your out-of-pocket costs, contact Aetna or ask your bariatric center professionals for assistance.