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Aetna and Weight Loss Surgery: What You Need to Know

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Aetna is one of the nation’s leading insurance providers and offers a range of plans that may cover medically necessary surgical procedures. If you’re planning surgery, knowing what’s included in your Aetna policy can help you make informed choices and avoid unexpected costs.

Whether you’re enrolled in an employer-sponsored plan, an individual policy, or through the healthcare marketplace, Aetna provides various plan levels. Each plan differs in its benefits, provider networks, and approval requirements.

Does Aetna Cover Weight Loss Surgery?

Yes – Aetna may cover bariatric surgery for eligible members when specific medical criteria are met. These qualifications include: a body mass index (BMI) of 40 or higher; a BMI of 35 or higher with obesity-related health conditions like type 2 diabetes, hypertension, cardiac issues, or sleep apnea, to name a few; documented evidence of participation in a physician-supervised weight management program; psychological evaluation; and nutritional counseling. Note that these requirements will vary between adults and adolescents, and those differences will be outlined in your specific insurance plan.

Which Procedures Are Covered?

If you’re exploring weight loss surgery, it’s important to understand how your Aetna plan works, what’s required for approval, and how to prepare for the process. Procedures such as gastric sleeve, gastric bypass, and duodenal switch may be covered when they are medically necessary and part of a comprehensive treatment plan for obesity. Your particular plan may also outline additional types of surgeries as covered or not covered. There also may be a clause in your policy that discusses experimental or investigational procedures, which are typically not covered. Talking with your healthcare provider about your options and with Aetna about what your specific plan will cover will help guide your planning efforts. 

What Else Should You Consider?

Many surgical procedures require prior authorization from Aetna. This means your surgeon must submit medical documentation proving that the procedure is medically necessary; it helps  to ensure that the surgery is appropriate and covered under your plan. Documentation that could be required includes medical history and physical exam notes, lab and imaging results, evidence of previous weight loss efforts, and letters of medical necessity from your healthcare providers. Your surgery clinic can typically help coordinate this step, but it’s wise to confirm with Aetna or check your member portal as well.

Important note: Failing to obtain prior authorization could result in claim denial or increased out-of-pocket costs so be sure not to skip this step. Also, keep in mind that the exam notes and weight loss efforts must be recent, typically within the previous two years. 

What Are Some Potential Out-of-Pocket Expenses?

Even with Aetna coverage, you’ll likely be responsible for part of the cost, depending on your specific plan. Some expenses you’ll need to consider include meeting your deductible, paying a copay or coinsurance, and out-of-network provider or facility penalties. This information should be outlined in your “Explanation or Benefits” (EOB) section of your insurance plan. Many patients find it helpful to speak with our billing team to review a cost estimate before surgery and understand what insurance will and will not cover. 

It is possible for some patients not to be approved on the first attempt. If a claim is not approved, denials can likely be appealed, and your care team can guide that process.

Unfortunately, there are instances in which insurance is a no-go. If after the denial and appeal process you still cannot gain coverage, you have other options. VIPSurg offers a cash pay rate starting at $9,750 for patients interested in the gastric sleeve, and you can get more details here. You also may be able to talk to your HR representative about using funds from a health savings plan (HSA) or consult with a financial advisor about medical loan options.

What You Can Do to Prepare

Here are steps to take before your procedure:

  • Call Aetna or log in to your member portal to confirm your benefits.
  • Ask your surgeon’s office to submit any required prior authorizations.
  • Review any out-of-pocket cost estimates with your healthcare provider.
  • Check your plan’s network to ensure all providers and facilities involved are covered.
  • Keep records of all communication with Aetna and your providers.

Have Questions? We’re Here to Help.

Our team is experienced in working with Aetna and can help guide you through the insurance process before, during, and after your surgery. If you have questions about coverage or billing, feel free to reach out.