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Obesity Surgery |
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Which surgeries are covered? Because of the high-risk nature of obesity surgery, the plan covers just two surgeries, and only in very specific circumstances.
Aetna covers the Roux-en-Y surgery for members ages 21 through 64 and laparoscopic adjustable gastric banding for members ages 18 through 64. Which surgery a member has is a decision made by the surgeon at the Center of Excellence and the member after the member meets all criteria for coverage. Members ages 65 or older who are interested in obesity surgery should check with Medicare for coverage. If Medicare approves obesity surgery, Aetna will pay second after Medicare. Who will be considered for coverage of obesity surgery?
Because obesity surgery requires dramatic and permanent lifestyle changes, these surgeries are not for everyone. Members first must meet strict criteria to be considered.
The list of requirements includes but is not limited to having a body mass index of 40 or higher and having a chronic disease such as diabetes, high cholesterol, or high blood pressure. See Criteria for coverage for complete information. If you are eligible for the presurgical program, you will need to pay for and participate in the Accomplish Bariatric Nutrition Services program*, which will help you follow a diet and exercise regimen to lose 5 percent of your initial program entrance body weight. The final decision to approve surgery is made by an Aetna medical director after all presurgical requirements are met. Once approved, you must use providers and facilities designated as Centers of Excellence by the Washington State Health Care Authority. Who will not be considered for coverage of obesity surgery?
Members who have had any obesity surgery within the last 10 years or any prior obesity surgery covered by a PEBB health plan are not eligible for coverage.
*The Accomplish enrollment fee is $1,450. The Aetna Public Employees Plan does not cover this service. You are responsible for the full program cost. The $1,450 cost does not apply to your plan deductible or annual out-of-pocket maximum.
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Criteria for coverage |
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