Obesity Surgery Criteria for Coverage

To be considered for coverage of obesity surgery, members must meet the following criteria. They also must comply with all presurgical requirements set by Aetna through case management. The decision to approve obesity surgery can be delayed, or even denied, if previously approved candidates do not comply with these requirements.

All criteria listed below must be met:

1. Be between the ages of 21–64 for coverage of Roux-en-Y surgery and between the ages of 18–64 for laparoscopic adjustable gastric banding surgery. (Members enrolled in Medicare should check with Medicare for coverage.)
2. Have not had any type of obesity surgery within the last 10 years.
3. Be morbidly obese with a body mass index (BMI) of 40 or greater.
4. Be diagnosed with one of the following diseases: diabetes, hypertension, high cholesterol (hyperlipidemia or dyslipidemia), sleep apnea, Pickwickian syndrome, or Pseudotumor Cerebri.
5. Have evidence of previously failed attempts at losing weight.
6. Have a psychological evaluation that indicates a strong readiness for change and absence of mental disorders that could impact the success of the surgery.
7. Be committed to working with a case manager during the preoperative period and complying with all presurgical requirements. These requirements include, but aren't limited to, completing a documented diet and exercise program and achieving a 5 percent weight loss after acceptance into the presurgical program.
8. Agree to continue participation and communication with case management for two years after surgery.
9. Not have medical conditions that would increase the risk of surgical mortality (death) or morbidity (complications) including but not limited to the following conditions: unstable coronary artery disease, severe pulmonary disease, portal hypertension with gastric or intestinal varices or other conditions thought to seriously compromise anesthesia or wound healing.

Women of Childbearing Age
Women of childbearing age who want to be considered for obesity surgery must be able to show they have received reproductive and contraceptive counseling. They must commit to not becoming pregnant after surgery until their provider determines it’s safe to do so. They must inform their provider and case manager what secure birth control method they will use during this period. They must be able to show that they have been informed about the risk of maternal malnutrition, which may impair normal fetal development.

Criteria for coverage
How to request coverage
Questionnaire to Request Coverage
FAQs about obesity surgery