Aetna · Clinical coverage policy

Aetna Obesity Surgery coverage criteria

Aetna covers bariatric surgery (RYGB, sleeve gastrectomy, adjustable gastric banding, BPD, duodenal switch, SADI-S, SIPS) for adults with a BMI over 40 (over 37.5 for Asian ancestry), or BMI over 35 (over 32.5 Asian) plus a qualifying severe obesity-related comorbidity, and for adolescents who have completed bone growth with a BMI over 40. The key gates are documented failure of past weight-loss attempts plus participation in an intensive multicomponent behavioral intervention (12+ sessions within 2 years before surgery) and a behavioral-health psychosocial assessment. Many newer, endoscopic, and revisional procedures (e.g., intragastric balloon, AspireAssist, gastric plication, vagus nerve blocking, mini/loop gastric bypass) are considered experimental/investigational, and surgery is not covered when selection criteria are unmet or for repeat surgery driven by post-op noncompliance.

Policy CPB 0157 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0157

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0157 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Obesity Surgery (CPT 43644), and what gets it denied?

Path
Aetna covers bariatric surgery (RYGB, sleeve gastrectomy, adjustable gastric banding, BPD, duodenal switch, SADI-S, SIPS) for adults with a BMI over 40 (over 37.5 for Asian ancestry), or BMI over 35 (over 32.5 Asian) plus a qualifying severe obesity-related comorbidity, and for adolescents who have completed bone growth with a BMI over 40. The key gates are documented failure of past weight-loss attempts plus participation in an intensive multicomponent behavioral intervention (12+ sessions within 2 years before surgery) and a behavioral-health psychosocial assessment. Many newer, endoscopic, and revisional procedures (e.g., intragastric balloon, AspireAssist, gastric plication, vagus nerve blocking, mini/loop gastric bypass) are considered experimental/investigational, and surgery is not covered when selection criteria are unmet or for repeat surgery driven by post-op noncompliance. Coverage criteria include: Procedures Aetna considers medically necessary for primary bariatric surgery (when selection criteria met): open or laparoscopic Roux-en-Y gastric bypass (RYGB); laparoscopic adjustable silicone gastric banding (LASGB); sleeve gastrectomy; biliopancreatic diversion (BPD); duodenal switch (DS); single anastomosis duodenal-ileal switch (SADI-S); and sleeve gastrectomy with single anastomosis duodeno-ileal bypass (SIPS); Adult selection criteria (age 18+) require ALL of: (1) BMI criterion met; AND (2) failed conservative treatment / behavioral intervention met; AND (3) psychosocial assessment performed; Adult BMI criterion (ONE of): (a) BMI exceeding 40 (or exceeding 37.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program; OR (b) BMI greater than 35 (or exceeding 32.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program, in conjunction with ANY of the qualifying severe comorbidities; Qualifying severe comorbidities for the lower-BMI (>35 / >32.5 Asian) pathway (ANY one of): clinically significant obstructive sleep apnea (meeting treatment criteria per CPB 0004); OR coronary heart disease with objective documentation (exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); OR medically refractory hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 antihypertensive agents of different classes); OR type 2 diabetes mellitus; OR nonalcoholic steatohepatitis (NASH) determined via liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test; Adult failed-conservative-treatment criterion (ALL of): member has attempted weight loss in the past without successful long-term weight reduction; AND member has participated in an intensive multicomponent behavioral intervention designed to achieve or maintain weight loss through dietary changes and increased physical activity; Intensive multicomponent behavioral intervention requirements (ALL of): participation documented in medical records with documentation of compliance (formal program records, e.g., Weight Watchers or Jenny Craig, may substitute for medical records); program must be intensive = 12 or more sessions on separate dates over any duration, occurring within 2 years prior to surgery (program may extend beyond 2 years if the final session occurred within the 2 years prior to surgery); may be in-person or remote, group- or individual-based; must include components focusing on nutrition, physical activity, and behavioral modification (self-monitoring, identifying barriers, problem-solving); may be supervised by behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, or other staff; Adult psychosocial assessment criterion: member must be assessed by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; any identified issues must receive appropriate referral and treatment; member should be educated about potential new psychosocial problems that may arise post-surgery; Adolescent selection criteria (ALL of): adolescent has completed bone growth (generally age 13 in girls and age 15 in boys); AND presence of obesity with BMI exceeding 40; Vertical banded gastroplasty (VBG) is medically necessary for members who meet the selection criteria for obesity surgery AND who are at increased risk of adverse consequences of RYGB due to presence of ANY of the following comorbid conditions: demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; OR hepatic cirrhosis with elevated liver function tests; OR inflammatory bowel disease (Crohn's disease or ulcerative colitis); OR poorly controlled systemic disease (ASA Class IV); OR radiation enteritis; Removal of a gastric band is medically necessary when recommended by the member's physician; Surgery to correct bariatric surgery complications (obstruction, stricture, erosion, band slippage) is medically necessary; Surgery for Candy cane syndrome (Roux syndrome) is medically necessary when the member is symptomatic (abdominal pain, nausea, and emesis) AND the diagnosis is confirmed by endoscopy or upper gastrointestinal contrast studies; Replacement of an adjustable gastric band is medically necessary if complications (e.g., port leakage, slippage) cannot be corrected with manipulation or adjustments; Conversion of sleeve gastrectomy to RYGB for GERD treatment is medically necessary when ALL of: (i) reflux documented by upper GI radiology, abnormal 24-hour pH monitoring, or endoscopically proven esophagitis after sleeve gastrectomy; AND (ii) ONE of the following: moderate-to-severe GERD incompletely controlled by optimal medical therapy (at least 1 month twice-daily PPI) and lifestyle modifications; OR responded to PPI therapy but experienced complications requiring discontinuation; OR complications of GERD (severe esophagitis [typically Los Angeles class C or D] or benign peptic stricture) with no response to optimal medical therapy; OR high-volume reflux; OR respiratory symptoms accompanied by typical reflux symptoms and positive esophageal pH testing; OR large hiatal hernia (more than 2 cm diameter, measured endoscopically). [When performed primarily for reflux meeting these criteria, the conversion is not considered repeat bariatric surgery]; Repeat bariatric surgery is medically necessary for members whose initial surgery was medically necessary, meeting ANY of: (a) conversion to sleeve gastrectomy, RYGB, or BPD/DS if inadequate success (less than 50% excess body weight loss) 2 years after the primary surgery, with member compliance with the prescribed nutrition and exercise program; OR (b) revision of a primary procedure that failed due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilated gastrojejunostomy anastomosis, if the primary procedure was initially successful in inducing weight loss and the member was compliant with the prescribed nutrition and exercise program; OR (c) conversion from an adjustable band to sleeve gastrectomy, RYGB, or BPD/DS if the member was compliant with the prescribed nutrition and exercise program following the band procedure, with complications not correctable via manipulation, adjustments, or replacement; Routine cholecystectomy is medically necessary when performed in concert with elective bariatric procedures (high incidence of gallbladder disease [28%] documented after obesity surgery); Concurrent hiatus hernia repair during bariatric surgery is considered incidental to the primary bariatric procedure (and not separately reimbursable). Applies to 14 codes: 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Persistent severe obesity documented in contemporaneous clinical records; BMI measured prior to the preoperative preparatory program (documented); Severe comorbidities supported by objective documentation (e.g., for coronary heart disease: exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); For NASH: documentation by liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test; Documentation in the medical record of the member's participation in an intensive multicomponent behavioral intervention, including documentation of compliance with the program (records from a formal program such as Weight Watchers or Jenny Craig may substitute for medical records); Documentation that the member has attempted weight loss in the past without successful long-term weight reduction; Documentation of psychosocial assessment by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; For repeat/revision surgery: documentation of compliance with the prescribed nutrition and exercise program (and, where applicable, documentation of less than 50% excess body weight loss at 2 years or initial successful weight loss for the failed primary procedure).
Trap
Policy exclusions and limitations: Adjunctive omentectomy to bariatric surgery is experimental, investigational, or unproven; AspireAssist aspiration therapy is experimental, investigational, or unproven; "Band over bypass" (LASGB revision of prior RYGB for management of weight regain) is experimental, investigational, or unproven; "Band over sleeve" (LASGB revision of prior sleeve gastrectomy) is experimental, investigational, or unproven; Bariatric/metabolic surgery as treatment for rheumatoid arthritis is experimental, investigational, or unproven; Bariatric surgery as treatment for idiopathic intracranial hypertension in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for infertility in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for type-2 diabetes in persons with BMI less than 35 is experimental, investigational, or unproven; Conversion of sleeve gastrectomy to RYGB for bile reflux is experimental, investigational, or unproven; Conversion to sleeve gastrectomy for hypoglycemia following RYGB is experimental, investigational, or unproven; Duodenal ileal switch for treatment of gastroparesis is experimental, investigational, or unproven; Gastric bypass as treatment for gastroparesis in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Gastroplasty ("stomach stapling"), distinct from vertical banded gastroplasty, is experimental, investigational, or unproven; Laparoscopic gastric diversion with gastro-jejunal reconstruction for GERD with esophagitis is experimental, investigational, or unproven; Laparoscopic gastric plication (laparoscopic greater curvature plication / LGCP), with or without gastric banding, is experimental, investigational, or unproven; Laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication is experimental, investigational, or unproven; LASGB, RYGB, and BPD/DS procedures not meeting the stated medical necessity criteria are experimental, investigational, or unproven; Liposuction (suction-assisted lipectomy; ultrasonic-assisted liposuction) is experimental, investigational, or unproven; Loop gastric bypass is experimental, investigational, or unproven; Mini gastric bypass is experimental, investigational, or unproven; Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery are experimental, investigational, or unproven, including: endoscopic outlet reduction (transoral outlet reduction / TORe) for weight gain after RYGB; gastrointestinal liners (endoscopic duodenal-jejunal bypass; EndoBarrier; ValenTx Endo Bypass System); intragastric balloon (e.g., Obalon Balloon System, ReShape Integrated Dual Balloon System); mini sleeve gastrectomy; restorative obesity surgery, endoluminal (ROSE) procedure for weight regain after gastric bypass; transoral gastroplasty (vertical sutured gastroplasty; endoluminal vertical gastroplasty; endoscopic sleeve gastroplasty); and use of endoscopic closure devices (Over the Scope clip / OTSC system, Apollo OverStitch, StomaphyX) with NOTES; Omentopexy during sleeve gastrectomy is experimental, investigational, or unproven; Open adjustable gastric banding is experimental, investigational, or unproven; Prophylactic mesh placement for incisional hernia prevention after open bariatric surgery is experimental, investigational, or unproven; Prophylactic pyloroplasty via botulinum toxin injection following laparoscopic sleeve gastrectomy is experimental, investigational, or unproven; Revision of RYGB by distalization is experimental, investigational, or unproven; RYGB for gastroesophageal reflux in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Roux-en-Y gastrojejunostomy for persistent GERD following antireflux surgery in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Sclerotherapy for dilated gastrojejunostomy following bariatric surgery is experimental, investigational, or unproven; Silastic ring vertical gastric bypass (Fobi pouch) is experimental, investigational, or unproven; Use of a coated stent for gastro-jejunal fistula following bariatric surgery is experimental, investigational, or unproven; Vagus nerve blocking (VBLOC device, Maestro Implant, Maestro Rechargeable System) is experimental, investigational, or unproven; Vertical banded gastroplasty (VBG) is experimental, investigational, or unproven except in the limited circumstances where medical necessity criteria for VBG are met; Measurement of serum C-reactive protein as a predictor for complications following bariatric surgery is not covered (effectiveness not established); Routine liver biopsy during bariatric surgery is not medically necessary in the absence of signs or symptoms of liver disease (elevated liver enzymes, enlarged liver); LASGB is not covered when the patient has a prior history of Roux-en-Y gastric bypass; LASGB is not covered when the patient has a prior history of sleeve gastrectomy; LASGB is not covered when performed with gastric plication; Obesity surgery is not covered when selection criteria are not met, including: BMI less than 40 (or less than 37.5 for Asian ancestry) without significant comorbidities; BMI 35-40 (or 32.5-37.5 for Asian ancestry) without qualifying severe comorbidities; adolescents with BMI less than 40 or who have not completed bone growth; no documented history of failed medical weight loss attempts; no participation in an intensive multicomponent behavioral intervention (12+ sessions over any duration within 2 years prior to surgery); or inadequate psychosocial assessment for substance use disorders or maladaptive eating behaviors; Obesity surgery is not covered in the presence of (psychosocial contraindications identified at assessment): active substance abuse disorders; uncontrolled eating disorders; untreated major depression or psychosis; active schizophrenia; or borderline personality disorder; Repeat / revision bariatric surgery is not covered when: the initial surgery did not meet medical necessity criteria; OR the patient was non-compliant with the prescribed nutrition and exercise program post-operatively; OR the conversion surgery is for weight regain due to non-compliance; OR there is no documented adequate prior weight loss (i.e., less than 50% excess body weight loss at 2 years) supporting revision; Concurrent hiatus hernia repair in bariatric surgery is considered incidental and not separately reimbursable. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0157 — Obesity Surgery

Coverage criteria

  • Procedures Aetna considers medically necessary for primary bariatric surgery (when selection criteria met): open or laparoscopic Roux-en-Y gastric bypass (RYGB); laparoscopic adjustable silicone gastric banding (LASGB); sleeve gastrectomy; biliopancreatic diversion (BPD); duodenal switch (DS); single anastomosis duodenal-ileal switch (SADI-S); and sleeve gastrectomy with single anastomosis duodeno-ileal bypass (SIPS)
  • Adult selection criteria (age 18+) require ALL of: (1) BMI criterion met; AND (2) failed conservative treatment / behavioral intervention met; AND (3) psychosocial assessment performed
  • Adult BMI criterion (ONE of): (a) BMI exceeding 40 (or exceeding 37.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program; OR (b) BMI greater than 35 (or exceeding 32.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program, in conjunction with ANY of the qualifying severe comorbidities
  • Qualifying severe comorbidities for the lower-BMI (>35 / >32.5 Asian) pathway (ANY one of): clinically significant obstructive sleep apnea (meeting treatment criteria per CPB 0004); OR coronary heart disease with objective documentation (exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); OR medically refractory hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 antihypertensive agents of different classes); OR type 2 diabetes mellitus; OR nonalcoholic steatohepatitis (NASH) determined via liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test
  • Adult failed-conservative-treatment criterion (ALL of): member has attempted weight loss in the past without successful long-term weight reduction; AND member has participated in an intensive multicomponent behavioral intervention designed to achieve or maintain weight loss through dietary changes and increased physical activity
  • Intensive multicomponent behavioral intervention requirements (ALL of): participation documented in medical records with documentation of compliance (formal program records, e.g., Weight Watchers or Jenny Craig, may substitute for medical records); program must be intensive = 12 or more sessions on separate dates over any duration, occurring within 2 years prior to surgery (program may extend beyond 2 years if the final session occurred within the 2 years prior to surgery); may be in-person or remote, group- or individual-based; must include components focusing on nutrition, physical activity, and behavioral modification (self-monitoring, identifying barriers, problem-solving); may be supervised by behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, or other staff
  • Adult psychosocial assessment criterion: member must be assessed by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; any identified issues must receive appropriate referral and treatment; member should be educated about potential new psychosocial problems that may arise post-surgery
  • Adolescent selection criteria (ALL of): adolescent has completed bone growth (generally age 13 in girls and age 15 in boys); AND presence of obesity with BMI exceeding 40
  • Vertical banded gastroplasty (VBG) is medically necessary for members who meet the selection criteria for obesity surgery AND who are at increased risk of adverse consequences of RYGB due to presence of ANY of the following comorbid conditions: demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; OR hepatic cirrhosis with elevated liver function tests; OR inflammatory bowel disease (Crohn's disease or ulcerative colitis); OR poorly controlled systemic disease (ASA Class IV); OR radiation enteritis
  • Removal of a gastric band is medically necessary when recommended by the member's physician
  • Surgery to correct bariatric surgery complications (obstruction, stricture, erosion, band slippage) is medically necessary
  • Surgery for Candy cane syndrome (Roux syndrome) is medically necessary when the member is symptomatic (abdominal pain, nausea, and emesis) AND the diagnosis is confirmed by endoscopy or upper gastrointestinal contrast studies
  • Replacement of an adjustable gastric band is medically necessary if complications (e.g., port leakage, slippage) cannot be corrected with manipulation or adjustments
  • Conversion of sleeve gastrectomy to RYGB for GERD treatment is medically necessary when ALL of: (i) reflux documented by upper GI radiology, abnormal 24-hour pH monitoring, or endoscopically proven esophagitis after sleeve gastrectomy; AND (ii) ONE of the following: moderate-to-severe GERD incompletely controlled by optimal medical therapy (at least 1 month twice-daily PPI) and lifestyle modifications; OR responded to PPI therapy but experienced complications requiring discontinuation; OR complications of GERD (severe esophagitis [typically Los Angeles class C or D] or benign peptic stricture) with no response to optimal medical therapy; OR high-volume reflux; OR respiratory symptoms accompanied by typical reflux symptoms and positive esophageal pH testing; OR large hiatal hernia (more than 2 cm diameter, measured endoscopically). [When performed primarily for reflux meeting these criteria, the conversion is not considered repeat bariatric surgery]
  • Repeat bariatric surgery is medically necessary for members whose initial surgery was medically necessary, meeting ANY of: (a) conversion to sleeve gastrectomy, RYGB, or BPD/DS if inadequate success (less than 50% excess body weight loss) 2 years after the primary surgery, with member compliance with the prescribed nutrition and exercise program; OR (b) revision of a primary procedure that failed due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilated gastrojejunostomy anastomosis, if the primary procedure was initially successful in inducing weight loss and the member was compliant with the prescribed nutrition and exercise program; OR (c) conversion from an adjustable band to sleeve gastrectomy, RYGB, or BPD/DS if the member was compliant with the prescribed nutrition and exercise program following the band procedure, with complications not correctable via manipulation, adjustments, or replacement
  • Routine cholecystectomy is medically necessary when performed in concert with elective bariatric procedures (high incidence of gallbladder disease [28%] documented after obesity surgery)
  • Concurrent hiatus hernia repair during bariatric surgery is considered incidental to the primary bariatric procedure (and not separately reimbursable)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Persistent severe obesity documented in contemporaneous clinical records
  • BMI measured prior to the preoperative preparatory program (documented)
  • Severe comorbidities supported by objective documentation (e.g., for coronary heart disease: exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction)
  • For NASH: documentation by liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test
  • Documentation in the medical record of the member's participation in an intensive multicomponent behavioral intervention, including documentation of compliance with the program (records from a formal program such as Weight Watchers or Jenny Craig may substitute for medical records)
  • Documentation that the member has attempted weight loss in the past without successful long-term weight reduction
  • Documentation of psychosocial assessment by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors
  • For repeat/revision surgery: documentation of compliance with the prescribed nutrition and exercise program (and, where applicable, documentation of less than 50% excess body weight loss at 2 years or initial successful weight loss for the failed primary procedure)

Frequently asked questions

When does Aetna cover Obesity Surgery (CPT 43644), and what gets it denied?
Aetna covers bariatric surgery (RYGB, sleeve gastrectomy, adjustable gastric banding, BPD, duodenal switch, SADI-S, SIPS) for adults with a BMI over 40 (over 37.5 for Asian ancestry), or BMI over 35 (over 32.5 Asian) plus a qualifying severe obesity-related comorbidity, and for adolescents who have completed bone growth with a BMI over 40. The key gates are documented failure of past weight-loss attempts plus participation in an intensive multicomponent behavioral intervention (12+ sessions within 2 years before surgery) and a behavioral-health psychosocial assessment. Many newer, endoscopic, and revisional procedures (e.g., intragastric balloon, AspireAssist, gastric plication, vagus nerve blocking, mini/loop gastric bypass) are considered experimental/investigational, and surgery is not covered when selection criteria are unmet or for repeat surgery driven by post-op noncompliance. Coverage criteria include: Procedures Aetna considers medically necessary for primary bariatric surgery (when selection criteria met): open or laparoscopic Roux-en-Y gastric bypass (RYGB); laparoscopic adjustable silicone gastric banding (LASGB); sleeve gastrectomy; biliopancreatic diversion (BPD); duodenal switch (DS); single anastomosis duodenal-ileal switch (SADI-S); and sleeve gastrectomy with single anastomosis duodeno-ileal bypass (SIPS); Adult selection criteria (age 18+) require ALL of: (1) BMI criterion met; AND (2) failed conservative treatment / behavioral intervention met; AND (3) psychosocial assessment performed; Adult BMI criterion (ONE of): (a) BMI exceeding 40 (or exceeding 37.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program; OR (b) BMI greater than 35 (or exceeding 32.5 for persons of Asian ancestry), measured prior to the preoperative preparatory program, in conjunction with ANY of the qualifying severe comorbidities; Qualifying severe comorbidities for the lower-BMI (>35 / >32.5 Asian) pathway (ANY one of): clinically significant obstructive sleep apnea (meeting treatment criteria per CPB 0004); OR coronary heart disease with objective documentation (exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); OR medically refractory hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 antihypertensive agents of different classes); OR type 2 diabetes mellitus; OR nonalcoholic steatohepatitis (NASH) determined via liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test; Adult failed-conservative-treatment criterion (ALL of): member has attempted weight loss in the past without successful long-term weight reduction; AND member has participated in an intensive multicomponent behavioral intervention designed to achieve or maintain weight loss through dietary changes and increased physical activity; Intensive multicomponent behavioral intervention requirements (ALL of): participation documented in medical records with documentation of compliance (formal program records, e.g., Weight Watchers or Jenny Craig, may substitute for medical records); program must be intensive = 12 or more sessions on separate dates over any duration, occurring within 2 years prior to surgery (program may extend beyond 2 years if the final session occurred within the 2 years prior to surgery); may be in-person or remote, group- or individual-based; must include components focusing on nutrition, physical activity, and behavioral modification (self-monitoring, identifying barriers, problem-solving); may be supervised by behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, or other staff; Adult psychosocial assessment criterion: member must be assessed by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; any identified issues must receive appropriate referral and treatment; member should be educated about potential new psychosocial problems that may arise post-surgery; Adolescent selection criteria (ALL of): adolescent has completed bone growth (generally age 13 in girls and age 15 in boys); AND presence of obesity with BMI exceeding 40; Vertical banded gastroplasty (VBG) is medically necessary for members who meet the selection criteria for obesity surgery AND who are at increased risk of adverse consequences of RYGB due to presence of ANY of the following comorbid conditions: demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; OR hepatic cirrhosis with elevated liver function tests; OR inflammatory bowel disease (Crohn's disease or ulcerative colitis); OR poorly controlled systemic disease (ASA Class IV); OR radiation enteritis; Removal of a gastric band is medically necessary when recommended by the member's physician; Surgery to correct bariatric surgery complications (obstruction, stricture, erosion, band slippage) is medically necessary; Surgery for Candy cane syndrome (Roux syndrome) is medically necessary when the member is symptomatic (abdominal pain, nausea, and emesis) AND the diagnosis is confirmed by endoscopy or upper gastrointestinal contrast studies; Replacement of an adjustable gastric band is medically necessary if complications (e.g., port leakage, slippage) cannot be corrected with manipulation or adjustments; Conversion of sleeve gastrectomy to RYGB for GERD treatment is medically necessary when ALL of: (i) reflux documented by upper GI radiology, abnormal 24-hour pH monitoring, or endoscopically proven esophagitis after sleeve gastrectomy; AND (ii) ONE of the following: moderate-to-severe GERD incompletely controlled by optimal medical therapy (at least 1 month twice-daily PPI) and lifestyle modifications; OR responded to PPI therapy but experienced complications requiring discontinuation; OR complications of GERD (severe esophagitis [typically Los Angeles class C or D] or benign peptic stricture) with no response to optimal medical therapy; OR high-volume reflux; OR respiratory symptoms accompanied by typical reflux symptoms and positive esophageal pH testing; OR large hiatal hernia (more than 2 cm diameter, measured endoscopically). [When performed primarily for reflux meeting these criteria, the conversion is not considered repeat bariatric surgery]; Repeat bariatric surgery is medically necessary for members whose initial surgery was medically necessary, meeting ANY of: (a) conversion to sleeve gastrectomy, RYGB, or BPD/DS if inadequate success (less than 50% excess body weight loss) 2 years after the primary surgery, with member compliance with the prescribed nutrition and exercise program; OR (b) revision of a primary procedure that failed due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilated gastrojejunostomy anastomosis, if the primary procedure was initially successful in inducing weight loss and the member was compliant with the prescribed nutrition and exercise program; OR (c) conversion from an adjustable band to sleeve gastrectomy, RYGB, or BPD/DS if the member was compliant with the prescribed nutrition and exercise program following the band procedure, with complications not correctable via manipulation, adjustments, or replacement; Routine cholecystectomy is medically necessary when performed in concert with elective bariatric procedures (high incidence of gallbladder disease [28%] documented after obesity surgery); Concurrent hiatus hernia repair during bariatric surgery is considered incidental to the primary bariatric procedure (and not separately reimbursable). Applies to 14 codes: 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Persistent severe obesity documented in contemporaneous clinical records; BMI measured prior to the preoperative preparatory program (documented); Severe comorbidities supported by objective documentation (e.g., for coronary heart disease: exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); For NASH: documentation by liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test; Documentation in the medical record of the member's participation in an intensive multicomponent behavioral intervention, including documentation of compliance with the program (records from a formal program such as Weight Watchers or Jenny Craig may substitute for medical records); Documentation that the member has attempted weight loss in the past without successful long-term weight reduction; Documentation of psychosocial assessment by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; For repeat/revision surgery: documentation of compliance with the prescribed nutrition and exercise program (and, where applicable, documentation of less than 50% excess body weight loss at 2 years or initial successful weight loss for the failed primary procedure). Policy exclusions and limitations: Adjunctive omentectomy to bariatric surgery is experimental, investigational, or unproven; AspireAssist aspiration therapy is experimental, investigational, or unproven; "Band over bypass" (LASGB revision of prior RYGB for management of weight regain) is experimental, investigational, or unproven; "Band over sleeve" (LASGB revision of prior sleeve gastrectomy) is experimental, investigational, or unproven; Bariatric/metabolic surgery as treatment for rheumatoid arthritis is experimental, investigational, or unproven; Bariatric surgery as treatment for idiopathic intracranial hypertension in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for infertility in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for type-2 diabetes in persons with BMI less than 35 is experimental, investigational, or unproven; Conversion of sleeve gastrectomy to RYGB for bile reflux is experimental, investigational, or unproven; Conversion to sleeve gastrectomy for hypoglycemia following RYGB is experimental, investigational, or unproven; Duodenal ileal switch for treatment of gastroparesis is experimental, investigational, or unproven; Gastric bypass as treatment for gastroparesis in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Gastroplasty ("stomach stapling"), distinct from vertical banded gastroplasty, is experimental, investigational, or unproven; Laparoscopic gastric diversion with gastro-jejunal reconstruction for GERD with esophagitis is experimental, investigational, or unproven; Laparoscopic gastric plication (laparoscopic greater curvature plication / LGCP), with or without gastric banding, is experimental, investigational, or unproven; Laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication is experimental, investigational, or unproven; LASGB, RYGB, and BPD/DS procedures not meeting the stated medical necessity criteria are experimental, investigational, or unproven; Liposuction (suction-assisted lipectomy; ultrasonic-assisted liposuction) is experimental, investigational, or unproven; Loop gastric bypass is experimental, investigational, or unproven; Mini gastric bypass is experimental, investigational, or unproven; Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery are experimental, investigational, or unproven, including: endoscopic outlet reduction (transoral outlet reduction / TORe) for weight gain after RYGB; gastrointestinal liners (endoscopic duodenal-jejunal bypass; EndoBarrier; ValenTx Endo Bypass System); intragastric balloon (e.g., Obalon Balloon System, ReShape Integrated Dual Balloon System); mini sleeve gastrectomy; restorative obesity surgery, endoluminal (ROSE) procedure for weight regain after gastric bypass; transoral gastroplasty (vertical sutured gastroplasty; endoluminal vertical gastroplasty; endoscopic sleeve gastroplasty); and use of endoscopic closure devices (Over the Scope clip / OTSC system, Apollo OverStitch, StomaphyX) with NOTES; Omentopexy during sleeve gastrectomy is experimental, investigational, or unproven; Open adjustable gastric banding is experimental, investigational, or unproven; Prophylactic mesh placement for incisional hernia prevention after open bariatric surgery is experimental, investigational, or unproven; Prophylactic pyloroplasty via botulinum toxin injection following laparoscopic sleeve gastrectomy is experimental, investigational, or unproven; Revision of RYGB by distalization is experimental, investigational, or unproven; RYGB for gastroesophageal reflux in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Roux-en-Y gastrojejunostomy for persistent GERD following antireflux surgery in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Sclerotherapy for dilated gastrojejunostomy following bariatric surgery is experimental, investigational, or unproven; Silastic ring vertical gastric bypass (Fobi pouch) is experimental, investigational, or unproven; Use of a coated stent for gastro-jejunal fistula following bariatric surgery is experimental, investigational, or unproven; Vagus nerve blocking (VBLOC device, Maestro Implant, Maestro Rechargeable System) is experimental, investigational, or unproven; Vertical banded gastroplasty (VBG) is experimental, investigational, or unproven except in the limited circumstances where medical necessity criteria for VBG are met; Measurement of serum C-reactive protein as a predictor for complications following bariatric surgery is not covered (effectiveness not established); Routine liver biopsy during bariatric surgery is not medically necessary in the absence of signs or symptoms of liver disease (elevated liver enzymes, enlarged liver); LASGB is not covered when the patient has a prior history of Roux-en-Y gastric bypass; LASGB is not covered when the patient has a prior history of sleeve gastrectomy; LASGB is not covered when performed with gastric plication; Obesity surgery is not covered when selection criteria are not met, including: BMI less than 40 (or less than 37.5 for Asian ancestry) without significant comorbidities; BMI 35-40 (or 32.5-37.5 for Asian ancestry) without qualifying severe comorbidities; adolescents with BMI less than 40 or who have not completed bone growth; no documented history of failed medical weight loss attempts; no participation in an intensive multicomponent behavioral intervention (12+ sessions over any duration within 2 years prior to surgery); or inadequate psychosocial assessment for substance use disorders or maladaptive eating behaviors; Obesity surgery is not covered in the presence of (psychosocial contraindications identified at assessment): active substance abuse disorders; uncontrolled eating disorders; untreated major depression or psychosis; active schizophrenia; or borderline personality disorder; Repeat / revision bariatric surgery is not covered when: the initial surgery did not meet medical necessity criteria; OR the patient was non-compliant with the prescribed nutrition and exercise program post-operatively; OR the conversion surgery is for weight regain due to non-compliance; OR there is no documented adequate prior weight loss (i.e., less than 50% excess body weight loss at 2 years) supporting revision; Concurrent hiatus hernia repair in bariatric surgery is considered incidental and not separately reimbursable. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Obesity Surgery?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Persistent severe obesity documented in contemporaneous clinical records; BMI measured prior to the preoperative preparatory program (documented); Severe comorbidities supported by objective documentation (e.g., for coronary heart disease: exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction); For NASH: documentation by liver biopsy, or advanced hepatic fibrosis identified by FibroScan, FibroTest-ActiTest, magnetic resonance elastography, or Enhanced Liver Fibrosis (ELF) test; Documentation in the medical record of the member's participation in an intensive multicomponent behavioral intervention, including documentation of compliance with the program (records from a formal program such as Weight Watchers or Jenny Craig may substitute for medical records); Documentation that the member has attempted weight loss in the past without successful long-term weight reduction; Documentation of psychosocial assessment by a qualified behavioral health clinician for psychosocial functioning, substance use disorders, and maladaptive eating behaviors; For repeat/revision surgery: documentation of compliance with the prescribed nutrition and exercise program (and, where applicable, documentation of less than 50% excess body weight loss at 2 years or initial successful weight loss for the failed primary procedure).
What does Aetna exclude for Obesity Surgery?
Policy exclusions and limitations: Adjunctive omentectomy to bariatric surgery is experimental, investigational, or unproven; AspireAssist aspiration therapy is experimental, investigational, or unproven; "Band over bypass" (LASGB revision of prior RYGB for management of weight regain) is experimental, investigational, or unproven; "Band over sleeve" (LASGB revision of prior sleeve gastrectomy) is experimental, investigational, or unproven; Bariatric/metabolic surgery as treatment for rheumatoid arthritis is experimental, investigational, or unproven; Bariatric surgery as treatment for idiopathic intracranial hypertension in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for infertility in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Bariatric surgery as treatment for type-2 diabetes in persons with BMI less than 35 is experimental, investigational, or unproven; Conversion of sleeve gastrectomy to RYGB for bile reflux is experimental, investigational, or unproven; Conversion to sleeve gastrectomy for hypoglycemia following RYGB is experimental, investigational, or unproven; Duodenal ileal switch for treatment of gastroparesis is experimental, investigational, or unproven; Gastric bypass as treatment for gastroparesis in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Gastroplasty ("stomach stapling"), distinct from vertical banded gastroplasty, is experimental, investigational, or unproven; Laparoscopic gastric diversion with gastro-jejunal reconstruction for GERD with esophagitis is experimental, investigational, or unproven; Laparoscopic gastric plication (laparoscopic greater curvature plication / LGCP), with or without gastric banding, is experimental, investigational, or unproven; Laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication is experimental, investigational, or unproven; LASGB, RYGB, and BPD/DS procedures not meeting the stated medical necessity criteria are experimental, investigational, or unproven; Liposuction (suction-assisted lipectomy; ultrasonic-assisted liposuction) is experimental, investigational, or unproven; Loop gastric bypass is experimental, investigational, or unproven; Mini gastric bypass is experimental, investigational, or unproven; Natural orifice transoral endoscopic surgery (NOTES) techniques for bariatric surgery are experimental, investigational, or unproven, including: endoscopic outlet reduction (transoral outlet reduction / TORe) for weight gain after RYGB; gastrointestinal liners (endoscopic duodenal-jejunal bypass; EndoBarrier; ValenTx Endo Bypass System); intragastric balloon (e.g., Obalon Balloon System, ReShape Integrated Dual Balloon System); mini sleeve gastrectomy; restorative obesity surgery, endoluminal (ROSE) procedure for weight regain after gastric bypass; transoral gastroplasty (vertical sutured gastroplasty; endoluminal vertical gastroplasty; endoscopic sleeve gastroplasty); and use of endoscopic closure devices (Over the Scope clip / OTSC system, Apollo OverStitch, StomaphyX) with NOTES; Omentopexy during sleeve gastrectomy is experimental, investigational, or unproven; Open adjustable gastric banding is experimental, investigational, or unproven; Prophylactic mesh placement for incisional hernia prevention after open bariatric surgery is experimental, investigational, or unproven; Prophylactic pyloroplasty via botulinum toxin injection following laparoscopic sleeve gastrectomy is experimental, investigational, or unproven; Revision of RYGB by distalization is experimental, investigational, or unproven; RYGB for gastroesophageal reflux in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Roux-en-Y gastrojejunostomy for persistent GERD following antireflux surgery in persons not meeting obesity surgery medical necessity criteria is experimental, investigational, or unproven; Sclerotherapy for dilated gastrojejunostomy following bariatric surgery is experimental, investigational, or unproven; Silastic ring vertical gastric bypass (Fobi pouch) is experimental, investigational, or unproven; Use of a coated stent for gastro-jejunal fistula following bariatric surgery is experimental, investigational, or unproven; Vagus nerve blocking (VBLOC device, Maestro Implant, Maestro Rechargeable System) is experimental, investigational, or unproven; Vertical banded gastroplasty (VBG) is experimental, investigational, or unproven except in the limited circumstances where medical necessity criteria for VBG are met; Measurement of serum C-reactive protein as a predictor for complications following bariatric surgery is not covered (effectiveness not established); Routine liver biopsy during bariatric surgery is not medically necessary in the absence of signs or symptoms of liver disease (elevated liver enzymes, enlarged liver); LASGB is not covered when the patient has a prior history of Roux-en-Y gastric bypass; LASGB is not covered when the patient has a prior history of sleeve gastrectomy; LASGB is not covered when performed with gastric plication; Obesity surgery is not covered when selection criteria are not met, including: BMI less than 40 (or less than 37.5 for Asian ancestry) without significant comorbidities; BMI 35-40 (or 32.5-37.5 for Asian ancestry) without qualifying severe comorbidities; adolescents with BMI less than 40 or who have not completed bone growth; no documented history of failed medical weight loss attempts; no participation in an intensive multicomponent behavioral intervention (12+ sessions over any duration within 2 years prior to surgery); or inadequate psychosocial assessment for substance use disorders or maladaptive eating behaviors; Obesity surgery is not covered in the presence of (psychosocial contraindications identified at assessment): active substance abuse disorders; uncontrolled eating disorders; untreated major depression or psychosis; active schizophrenia; or borderline personality disorder; Repeat / revision bariatric surgery is not covered when: the initial surgery did not meet medical necessity criteria; OR the patient was non-compliant with the prescribed nutrition and exercise program post-operatively; OR the conversion surgery is for weight regain due to non-compliance; OR there is no documented adequate prior weight loss (i.e., less than 50% excess body weight loss at 2 years) supporting revision; Concurrent hiatus hernia repair in bariatric surgery is considered incidental and not separately reimbursable. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0157 — Obesity Surgery

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0157 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.