Does Aetna Cover Gastric Sleeve Surgery?

One of the principal concerns of many patients who are considering using Aetna health insurance to cover their gastric sleeve surgery is whether they will meet the necessary requirements of their plan.

Aetna coverage

At West Medical, as the premier weight loss surgery provider in southern California, we happily work with all PPO insurance plans, as long as you meet your insurance plan’s conditions for your bariatric surgery.

Gastric sleeve surgery, which is also known as laparoscopic sleeve gastrectomy surgery, is often a preferred choice for patients who want to lose weight and may have tried other alternative methods which have so far proved unsuccessful.

Gastric sleeve surgery has become the most widely used bariatric procedure as it can safely and effectively reduce appetite over time, making it far easier for patients to make dietary changes which can lead to successful long-term weight loss.

While you can review your insurance policy package to see what weight control expenses are covered or excluded, you may find it easier to simply give us a call, or text us now at (855) 690-0565 to verify your insurance details. One of our bariatric surgery insurance coordinators can verify your Aetna laparoscopic sleeve gastrectomy coverage for you.

There is absolutely no obligation to have us verify your gastric sleeve coverage and if you don’t meet your insurance policy’s criteria, we can request an individual need assessment, or send a letter of medical necessity on your behalf. We can also help you through the appeal process if necessary.

Aetna Laparoscopic Sleeve Gastrectomy Coverage

Just as each person is different, Aetna’s gastric sleeve surgery coverage and pre-approval criteria can vary with each insurance plan and prospective patient.

Prior to covering any bariatric surgery, Aetna requires you to have a Body Mass Index (BMI) of 35 or greater along with a written letter describing your weight history for the last 2 years including all attempted diets, exercise and weight loss programs.

You may also be required to undergo a 3-month supervised diet (nutritional evaluation) prior to qualifying for Aetna’s laparoscopic sleeve gastrectomy coverage. If Your BMI is below 40, Aetna will also evaluate your weight-related medical conditions prior to granting your authorization for gastric sleeve surgery.

Do You Meet the Aetna Health Insurance Requirements for Gastric Sleeve Surgery if You Are Over 18 Years Old?

You may automatically pre-qualify for Aetna1 to cover your gastric sleeve surgery if you are over 18 years old and meet the following criteria:

  • You have a Body Mass Index (BMI) exceeding 40 prior to a preoperative preparatory program

  • You have a BMI greater than 35 measured prior to the preoperative preparatory program

  • You have severe obstructive sleep apnea as a result of your weight, or

  • You have coronary heart disease, or

  • You have medically refractory hypertension, or

  • You have Type 2 diabetes, or

  • You have non-alcoholic steatohepatitis (NASH) which is an advanced form of non-alcoholic fatty liver disease, or

  • You have been overweight for at least two years, or

  • You have failed all weight-loss attempts including diets, exercise and weight loss programs

Do You Meet the Aetna Health Insurance Requirements to Have Gastric Sleeve Surgery if You Are an Adolescent?

You may automatically pre-qualify for Aetna to cover your gastric sleeve surgery if you are classed as an adolescent (11-17 years old) and meet the following criteria:

  • Your BMI exceeds 40 prior to a preoperative preparatory program and one of the following conditions:

  • You have severe obstructive sleep apnea as a result of your weight, or

  • You have Type 2 diabetes, or

  • You have non-alcoholic steatohepatitis (NASH) which is an advanced form of non-alcoholic fatty liver disease

  • You have pseudotumor comorbidities which include degenerative joint disease, gastroesophageal reflux disease, hypertension, urinary stress incontinence

If you have a BMI of 50 or more and you have one or more of the following conditions you may fit the criteria to have gastric sleeve surgery:

  • You have hypertension, or

  • You have dyslipidemias (elevated cholesterol of fats in your blood)

  • You have non-alcoholic steatohepatitis (NASH) which is an advanced form of non-alcoholic fatty liver disease, or

  • You have venous stasis disease (inflammation of the skin in the lower legs), or

  • You struggle to do daily activities due to your weight, or

  • You have soft tissue infections, or

  • You have stress urinary incontinence, or

  • You have gastroesophageal reflux disease, or

  • You are struggling with daily physical activity, or

  • You have obesity-related psychosocial distress

  • You have failed all weight-loss attempts including diets, exercise and weight loss programs

How to Find Out More About Aetna Insurance Coverage for Your Gastric Sleeve Surgery

To see if your Aetna insurance plan covers your gastric sleeve surgery, please call or text us now at (855) 690-0565 to verify your insurance details. One of our expert team will be available to help you with any questions you may have.

Aetna provides medical benefits in all 50 states to an estimated 39 million people. Members include employer groups, individuals, part-time and hourly workers, individuals and families on health plans, governmental units, individuals on government-sponsored plans, college students, labor groups and expatriates. Aetna has four PPO networks2 in California:

Aetna’s national network - The Aetna Open Access® Managed Choice® (OAMC) network is available in all California counties, except Mendocino, Sierra, Alpine, and Inyo. The network has more than 111,000 providers and 407 hospitals.

The Aetna Whole HealthSM – Southern California PPO network has more than 1,700 primary care physicians and 57 hospitals.

The Sutter Health Aetna joint venture network has more than 14,000 primary care physicians and specialists and 33 hospitals. Coverage in Amador County is currently for self-insured plans only. Fully insured plans have access to 32 hospitals.

The Savings Plus network, which is applicable to small group businesses only, has more than 39,000 providers and 208 hospitals.

Disclaimer: This site is not affiliated with or endorsed by Aetna and is for informational purposes only. The afore-mentioned Aetna gastric sleeve surgery guidelines have been compiled from various public sources. It is presented online for informational use only, and without warranty as to its accuracy, timeliness, or completeness. This site does not replace any official versions of the information presented, nor does inclusion on this list guarantee coverage. Please check your Aetna policy before proceeding with your surgery.

1 https://www.aetna.com/cpb/medical/data/100_199/0157.html

2 https://www.rbgcal.com/wp-content/uploads/2016/03/Aetna-CA-Network-Map-10.21.pdf

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