
Insurance Coverage and Weight loss Surgery
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Gastric Bypass Insurance Guidelines
AETNA GUIDELINES
Aetna only covers Roux-en-Y gastric bypass. They consider LAP BAND as experimental and will only cover it in specific individual cases.
Required Documentation:
- Presence of morbid obesity that has persisted for at least 5 years, defined as either:
- Body mass index (BMI)* exceeding 40; or
- BMI* greater than 35 in conjunction with the following severe co-morbidities that are likely to reduce life expectancy:
- Coronary heart disease; or
- Type 2 diabetes mellitus; or
- Obstructive sleep apnea; or
- Hypertension (BP> 140 mmHg systolic and /or 90 mmHg diastolic)
NOTE: A PHYSICIAN’S SUMMARY LETTER IS NOT SUFFICIENT DOCUMENTATION
- Patient has completed growth (18 years of age or documentation of completion of bone growth);
- Clinical records documenting the medical/dietary therapies (within two years prior to the surgery) by an attending physician who supervised the member’s participation.
- Documentation of five year weight history; AND
- Documentation of any medication that was prescribed by a physician to assist in weight loss; AND
- Co-morbidities and cardiac risk factors such as smoking, hypertension, family history, etc.; AND
- Surgical consult report indicating need for surgery.
Documentation of pre-operative evaluation and clearance for members who have a history of severe psychiatric disturbances or who are currently under the care of a psychologist / psychiatrist or who are on psychotropic medications. Aetna is denying our request for obesity surgery if this documentation is not provided, therefore we will not contact your insurance company until we receive this documentation.