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How long is the process to be approved for obesity surgery?
Does Aetna cover follow-up surgery to remove loose skin?
What does BMI mean?
Why does Aetna require a BMI of 40 or more as part of its criteria for coverage of obesity surgery?
What if I am in the super obese category (BMI greater than 50)?
What if I don't qualify for obesity surgery coverage under Aetna?
How often can I apply for coverage of obesity surgery?
How does case management for obesity surgery work?
Why does Aetna limit the providers I can use for obesity surgery?
How long is the process to be approved for obesity surgery?
The amount of time it takes depends a lot on you. After you submit your initial request for coverage, and if you are approved for the presurgical program, you must lose 5 percent of your body weight within six months. You will not be referred to an obesity surgery center for evaluation until you have met the weight loss requirements and have been turning in your diet and exercise reports. When you have completed all presurgical requirements, an Aetna medical director will make the final decision for coverage of obesity surgery.
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Does Aetna cover follow-up surgery to remove loose skin?
No. Aetna considers the removal of excess skin to be cosmetic, and therefore does not cover this procedure.
If you decide to pay for skin removal yourself, most plastic surgeons require that you wait two to three years following significant weight loss. This is because the skin tends to tighten somewhat over time.
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What does BMI mean?
The Body Mass Index (BMI) is a measurement of the ratio between height and weight. Those with a BMI of 25 or over generally have excess body fat in addition to being overweight for their height.
The World Health Organization (WHO) uses the following definitions for the obese category:
Severely Obese = BMI 35–39
Morbidly Obese = BMI 40–50
Super Obese = BMI over 50
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Why does Aetna require a BMI of 40 or more as part of its criteria for coverage of obesity surgery?
Our review of the medical literature supports using a BMI of 40 to 50, plus the existence of an obesity-related condition such as diabetes, as criteria for determining appropriate candidates for obesity surgery. Obesity surgery is for the morbidly obese.
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What if I am in the super obese category (BMI greater than 50)?
You may still qualify and can apply for coverage. But the increased risks involved with being in this high-risk category may require special expertise or other specific services.
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What if I don't qualify for obesity surgery coverage under Aetna?
If Aetna denies your request for obesity surgery, we may recommend other programs to help you make lifestyle changes. Dietary and exercise programs have shown to be effective tools for successful weight loss, when participants are committed. Be aware though that Aetna does not cover many of these services. Whether you have the surgery or not, eating less and increasing activity is key to achieving long-term weight loss.
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How often can I apply for coverage of obesity surgery?
You can apply once per calendar year.
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How does case management for obesity surgery work?
Candidates for obesity surgery are required to work with Aetna case managers to prepare for surgery. This is major, high-risk surgery, and Aetna wants to ensure that enrollees have the information they need to make informed decisions. There is no charge for case management services.
Aetna case managers are nurses with special expertise in coordinating care and helping patients with high risks or serious illness. Case managers help Aetna surgical candidates with issues related to obesity surgery such as:
- Making necessary lifestyle changes to support losing the required 5 percent of your initial verified weight.
- Offering alternative methods for achieving weight-loss goals.
- Understanding the risks, benefits and long-term effects of surgery.
- Providing realistic expectations of life after obesity surgery.
Aetna’s obesity surgery providers know that a well-prepared patient is more likely to be successful. We want you to be fully informed before making such a life-altering decision, a decision that affects not only you, but others in your life.
Please do not call case management prior to filling out the initial questionnaire. Case managers will not be able to assist you until you submit your information.
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Why does Aetna limit the providers I can use for obesity surgery?
The Health Care Authority Public Employees Health Plans has selected specific Centers of Excellence that meet their criteria and have proven positive outcomes. Enrollees may not choose their own doctor for this procedure. Aetna members will work with a case manager to decide which Center of Excellence is best for their procedure.
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