Aetna · Clinical coverage policy

Aetna Weight Reduction Programs coverage criteria

Aetna CPB 0039 covers clinician-supervised weight-loss counseling (up to 26 combined visits per 12 months for adults with BMI >= 30), medically appropriate diagnostic workup for overweight/obese members, very-low-calorie-diet lab monitoring for up to 16 weeks, and the FDA-cleared device Plenity (BMI 25-40, used with diet and exercise). Commercial diet programs, exercise equipment, special-diet/grocery supplements, hospital confinement for weight loss, and numerous unproven interventions (e.g., acupuncture, HCG injections, FTO genotyping, wearables) are excluded; bariatric surgery criteria and weight-loss-medication criteria live in separate bulletins (CPB 0157 and the Antiobesity Agents pharmacy policy).

Policy CPB 0039 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0039

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0039 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 Weight Reduction Programs (CPT 97802), and what gets it denied?

Path
Aetna CPB 0039 covers clinician-supervised weight-loss counseling (up to 26 combined visits per 12 months for adults with BMI >= 30), medically appropriate diagnostic workup for overweight/obese members, very-low-calorie-diet lab monitoring for up to 16 weeks, and the FDA-cleared device Plenity (BMI 25-40, used with diet and exercise). Commercial diet programs, exercise equipment, special-diet/grocery supplements, hospital confinement for weight loss, and numerous unproven interventions (e.g., acupuncture, HCG injections, FTO genotyping, wearables) are excluded; bariatric surgery criteria and weight-loss-medication criteria live in separate bulletins (CPB 0157 and the Antiobesity Agents pharmacy policy). Coverage criteria include: Clinician-supervised weight reduction counseling: up to a COMBINED limit of 26 individual or group visits by any recognized provider per 12-month period is medically necessary for weight reduction counseling in ADULTS who are obese (defined as BMI greater than or equal to 30 kg/m2).; Clinician-supervised weight reduction counseling in obese CHILDREN: number of visits is left to the discretion of the member's physician.; Plenity (Gelesis, Inc.), the FDA-cleared weight reduction device, is medically necessary to aid in weight management in overweight and obese ADULTS with a BMI of 25-40 kg/m2, WHEN used in conjunction with diet and exercise.; Very low calorie diet (VLCD) monitoring services are medically necessary for obese members who have been prescribed a VLCD (less than 799 Kcal/day; e.g., Optifast, Medifast), for up to 16 weeks after initiation of the VLCD, comprising ALL of the following: EKG after 50 lbs of weight loss; AND Lipid profile at the beginning and end of the VLCD program; AND Serum chemistries and liver function tests (SMA 20) weekly during the rapid weight loss phase of the VLCD, then every 2 weeks thereafter up to 16 weeks.; VLCDs extending beyond 16 weeks are subject to medical review to determine if additional services are medically necessary.; Medical evaluation / diagnostic workup of overweight or obese individuals is covered, including (as clinically indicated): complete blood count (CBC).; Medical evaluation diagnostic workup: comprehensive history and physical examination.; Medical evaluation diagnostic workup: dexamethasone suppression test and 24-hour urinary free cortisol (when Cushing's syndrome is suspected).; Medical evaluation diagnostic workup: electrocardiogram (EKG) in adults.; Medical evaluation diagnostic workup: glucose tolerance test (GTT).; Medical evaluation diagnostic workup: hand x-ray for bone age in children.; Medical evaluation diagnostic workup: lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides).; Medical evaluation diagnostic workup: metabolic and chemistry profile (SMA 20).; Medical evaluation diagnostic workup: thyroid function tests (T3, T4, TSH).; Medical evaluation diagnostic workup: urinalysis.; Weight reduction medications: the medical necessity criteria in this bulletin do NOT apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control; for weight reduction medications and associated criteria, see the Aetna Pharmacy CPB on Antiobesity Agents (criteria are maintained in the separate pharmacy policy, not this medical bulletin).; For Aetna's clinical policy on surgical management of obesity (bariatric/obesity surgery), see CPB 0157 - Obesity Surgery (surgical criteria are NOT contained in this bulletin).. Applies to 8 codes: 97802, 97803, 97804, G0270, G0271, S9449, S9451, S9452.
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: Confirmation of BMI status (BMI greater than or equal to 30 kg/m2 for adult counseling; BMI 25-40 kg/m2 for Plenity).; For VLCD: documentation of the VLCD prescription and weight-loss milestones (e.g., 50 lbs of weight loss triggering EKG).; For Plenity: documentation that the device is used in conjunction with diet and exercise.
Trap
Policy exclusions and limitations: Experimental/investigational/unproven: Acupuncture for weight loss.; Experimental/investigational/unproven: Air displacement plethysmography (BodPod).; Experimental/investigational/unproven: Body plethysmography (diagnostic study).; Experimental/investigational/unproven: Boron compound administration.; Experimental/investigational/unproven: Low-level laser therapy.; Experimental/investigational/unproven: Dual-energy X-ray (DEXA) body composition (diagnostic study).; Experimental/investigational/unproven: Fat mass and obesity-associated (FTO) genotyping.; Experimental/investigational/unproven: Gastric electrical stimulation.; Experimental/investigational/unproven: Human chorionic gonadotropin (HCG) or vitamin injections for weight loss.; Experimental/investigational/unproven: Indirect calorimetry (also known as oxygen uptake analysis; diagnostic study).; Experimental/investigational/unproven: Lipotropic injection (e.g., Lipo-B).; Experimental/investigational/unproven: Normo-baric hypoxic conditioning.; Experimental/investigational/unproven: Sodium-glucose co-transporter 2 inhibitors (for weight reduction).; Experimental/investigational/unproven: Wearable devices (e.g., Fitbit or health apps on mobile phones).; Experimental/investigational/unproven: Whole body calorimetry and composition, and whole body bio-impedance analysis, for weight reduction and other indications.; Specifically excluded from coverage under most benefit plans: Exercise programs or use of exercise equipment.; Specifically excluded from coverage under most benefit plans: Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods, or phytotherapy).; Specifically excluded from coverage under most benefit plans: Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.; Prepackaged food supplements or substitutes and grocery items are excluded.; Diagnostic tests required by non-covered weight loss programs (i.e., programs that do not require physician supervision) are not covered.; Hospital confinement is considered NOT medically necessary for a weight reduction program.; Note: Many/most Aetna benefit plans specifically EXCLUDE coverage of weight reduction medications, and specifically exclude services and supplies for weight reduction (check benefit plan descriptions for details); where excluded, the medical necessity criteria in this bulletin do not apply. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0039 — Weight Reduction Programs

Coverage criteria

  • Clinician-supervised weight reduction counseling: up to a COMBINED limit of 26 individual or group visits by any recognized provider per 12-month period is medically necessary for weight reduction counseling in ADULTS who are obese (defined as BMI greater than or equal to 30 kg/m2).
  • Clinician-supervised weight reduction counseling in obese CHILDREN: number of visits is left to the discretion of the member's physician.
  • Plenity (Gelesis, Inc.), the FDA-cleared weight reduction device, is medically necessary to aid in weight management in overweight and obese ADULTS with a BMI of 25-40 kg/m2, WHEN used in conjunction with diet and exercise.
  • Very low calorie diet (VLCD) monitoring services are medically necessary for obese members who have been prescribed a VLCD (less than 799 Kcal/day; e.g., Optifast, Medifast), for up to 16 weeks after initiation of the VLCD, comprising ALL of the following: EKG after 50 lbs of weight loss; AND Lipid profile at the beginning and end of the VLCD program; AND Serum chemistries and liver function tests (SMA 20) weekly during the rapid weight loss phase of the VLCD, then every 2 weeks thereafter up to 16 weeks.
  • VLCDs extending beyond 16 weeks are subject to medical review to determine if additional services are medically necessary.
  • Medical evaluation / diagnostic workup of overweight or obese individuals is covered, including (as clinically indicated): complete blood count (CBC).
  • Medical evaluation diagnostic workup: comprehensive history and physical examination.
  • Medical evaluation diagnostic workup: dexamethasone suppression test and 24-hour urinary free cortisol (when Cushing's syndrome is suspected).
  • Medical evaluation diagnostic workup: electrocardiogram (EKG) in adults.
  • Medical evaluation diagnostic workup: glucose tolerance test (GTT).
  • Medical evaluation diagnostic workup: hand x-ray for bone age in children.
  • Medical evaluation diagnostic workup: lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides).
  • Medical evaluation diagnostic workup: metabolic and chemistry profile (SMA 20).
  • Medical evaluation diagnostic workup: thyroid function tests (T3, T4, TSH).
  • Medical evaluation diagnostic workup: urinalysis.
  • Weight reduction medications: the medical necessity criteria in this bulletin do NOT apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control; for weight reduction medications and associated criteria, see the Aetna Pharmacy CPB on Antiobesity Agents (criteria are maintained in the separate pharmacy policy, not this medical bulletin).
  • For Aetna's clinical policy on surgical management of obesity (bariatric/obesity surgery), see CPB 0157 - Obesity Surgery (surgical criteria are NOT contained in this bulletin).

Covered codes

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

Documentation required

  • Confirmation of BMI status (BMI greater than or equal to 30 kg/m2 for adult counseling; BMI 25-40 kg/m2 for Plenity).
  • For VLCD: documentation of the VLCD prescription and weight-loss milestones (e.g., 50 lbs of weight loss triggering EKG).
  • For Plenity: documentation that the device is used in conjunction with diet and exercise.

Frequently asked questions

When does Aetna cover Weight Reduction Programs (CPT 97802), and what gets it denied?
Aetna CPB 0039 covers clinician-supervised weight-loss counseling (up to 26 combined visits per 12 months for adults with BMI >= 30), medically appropriate diagnostic workup for overweight/obese members, very-low-calorie-diet lab monitoring for up to 16 weeks, and the FDA-cleared device Plenity (BMI 25-40, used with diet and exercise). Commercial diet programs, exercise equipment, special-diet/grocery supplements, hospital confinement for weight loss, and numerous unproven interventions (e.g., acupuncture, HCG injections, FTO genotyping, wearables) are excluded; bariatric surgery criteria and weight-loss-medication criteria live in separate bulletins (CPB 0157 and the Antiobesity Agents pharmacy policy). Coverage criteria include: Clinician-supervised weight reduction counseling: up to a COMBINED limit of 26 individual or group visits by any recognized provider per 12-month period is medically necessary for weight reduction counseling in ADULTS who are obese (defined as BMI greater than or equal to 30 kg/m2).; Clinician-supervised weight reduction counseling in obese CHILDREN: number of visits is left to the discretion of the member's physician.; Plenity (Gelesis, Inc.), the FDA-cleared weight reduction device, is medically necessary to aid in weight management in overweight and obese ADULTS with a BMI of 25-40 kg/m2, WHEN used in conjunction with diet and exercise.; Very low calorie diet (VLCD) monitoring services are medically necessary for obese members who have been prescribed a VLCD (less than 799 Kcal/day; e.g., Optifast, Medifast), for up to 16 weeks after initiation of the VLCD, comprising ALL of the following: EKG after 50 lbs of weight loss; AND Lipid profile at the beginning and end of the VLCD program; AND Serum chemistries and liver function tests (SMA 20) weekly during the rapid weight loss phase of the VLCD, then every 2 weeks thereafter up to 16 weeks.; VLCDs extending beyond 16 weeks are subject to medical review to determine if additional services are medically necessary.; Medical evaluation / diagnostic workup of overweight or obese individuals is covered, including (as clinically indicated): complete blood count (CBC).; Medical evaluation diagnostic workup: comprehensive history and physical examination.; Medical evaluation diagnostic workup: dexamethasone suppression test and 24-hour urinary free cortisol (when Cushing's syndrome is suspected).; Medical evaluation diagnostic workup: electrocardiogram (EKG) in adults.; Medical evaluation diagnostic workup: glucose tolerance test (GTT).; Medical evaluation diagnostic workup: hand x-ray for bone age in children.; Medical evaluation diagnostic workup: lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides).; Medical evaluation diagnostic workup: metabolic and chemistry profile (SMA 20).; Medical evaluation diagnostic workup: thyroid function tests (T3, T4, TSH).; Medical evaluation diagnostic workup: urinalysis.; Weight reduction medications: the medical necessity criteria in this bulletin do NOT apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control; for weight reduction medications and associated criteria, see the Aetna Pharmacy CPB on Antiobesity Agents (criteria are maintained in the separate pharmacy policy, not this medical bulletin).; For Aetna's clinical policy on surgical management of obesity (bariatric/obesity surgery), see CPB 0157 - Obesity Surgery (surgical criteria are NOT contained in this bulletin).. Applies to 8 codes: 97802, 97803, 97804, G0270, G0271, S9449, S9451, S9452. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Confirmation of BMI status (BMI greater than or equal to 30 kg/m2 for adult counseling; BMI 25-40 kg/m2 for Plenity).; For VLCD: documentation of the VLCD prescription and weight-loss milestones (e.g., 50 lbs of weight loss triggering EKG).; For Plenity: documentation that the device is used in conjunction with diet and exercise. Policy exclusions and limitations: Experimental/investigational/unproven: Acupuncture for weight loss.; Experimental/investigational/unproven: Air displacement plethysmography (BodPod).; Experimental/investigational/unproven: Body plethysmography (diagnostic study).; Experimental/investigational/unproven: Boron compound administration.; Experimental/investigational/unproven: Low-level laser therapy.; Experimental/investigational/unproven: Dual-energy X-ray (DEXA) body composition (diagnostic study).; Experimental/investigational/unproven: Fat mass and obesity-associated (FTO) genotyping.; Experimental/investigational/unproven: Gastric electrical stimulation.; Experimental/investigational/unproven: Human chorionic gonadotropin (HCG) or vitamin injections for weight loss.; Experimental/investigational/unproven: Indirect calorimetry (also known as oxygen uptake analysis; diagnostic study).; Experimental/investigational/unproven: Lipotropic injection (e.g., Lipo-B).; Experimental/investigational/unproven: Normo-baric hypoxic conditioning.; Experimental/investigational/unproven: Sodium-glucose co-transporter 2 inhibitors (for weight reduction).; Experimental/investigational/unproven: Wearable devices (e.g., Fitbit or health apps on mobile phones).; Experimental/investigational/unproven: Whole body calorimetry and composition, and whole body bio-impedance analysis, for weight reduction and other indications.; Specifically excluded from coverage under most benefit plans: Exercise programs or use of exercise equipment.; Specifically excluded from coverage under most benefit plans: Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods, or phytotherapy).; Specifically excluded from coverage under most benefit plans: Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.; Prepackaged food supplements or substitutes and grocery items are excluded.; Diagnostic tests required by non-covered weight loss programs (i.e., programs that do not require physician supervision) are not covered.; Hospital confinement is considered NOT medically necessary for a weight reduction program.; Note: Many/most Aetna benefit plans specifically EXCLUDE coverage of weight reduction medications, and specifically exclude services and supplies for weight reduction (check benefit plan descriptions for details); where excluded, the medical necessity criteria in this bulletin do not apply. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Weight Reduction Programs?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Confirmation of BMI status (BMI greater than or equal to 30 kg/m2 for adult counseling; BMI 25-40 kg/m2 for Plenity).; For VLCD: documentation of the VLCD prescription and weight-loss milestones (e.g., 50 lbs of weight loss triggering EKG).; For Plenity: documentation that the device is used in conjunction with diet and exercise.
What does Aetna exclude for Weight Reduction Programs?
Policy exclusions and limitations: Experimental/investigational/unproven: Acupuncture for weight loss.; Experimental/investigational/unproven: Air displacement plethysmography (BodPod).; Experimental/investigational/unproven: Body plethysmography (diagnostic study).; Experimental/investigational/unproven: Boron compound administration.; Experimental/investigational/unproven: Low-level laser therapy.; Experimental/investigational/unproven: Dual-energy X-ray (DEXA) body composition (diagnostic study).; Experimental/investigational/unproven: Fat mass and obesity-associated (FTO) genotyping.; Experimental/investigational/unproven: Gastric electrical stimulation.; Experimental/investigational/unproven: Human chorionic gonadotropin (HCG) or vitamin injections for weight loss.; Experimental/investigational/unproven: Indirect calorimetry (also known as oxygen uptake analysis; diagnostic study).; Experimental/investigational/unproven: Lipotropic injection (e.g., Lipo-B).; Experimental/investigational/unproven: Normo-baric hypoxic conditioning.; Experimental/investigational/unproven: Sodium-glucose co-transporter 2 inhibitors (for weight reduction).; Experimental/investigational/unproven: Wearable devices (e.g., Fitbit or health apps on mobile phones).; Experimental/investigational/unproven: Whole body calorimetry and composition, and whole body bio-impedance analysis, for weight reduction and other indications.; Specifically excluded from coverage under most benefit plans: Exercise programs or use of exercise equipment.; Specifically excluded from coverage under most benefit plans: Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods, or phytotherapy).; Specifically excluded from coverage under most benefit plans: Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.; Prepackaged food supplements or substitutes and grocery items are excluded.; Diagnostic tests required by non-covered weight loss programs (i.e., programs that do not require physician supervision) are not covered.; Hospital confinement is considered NOT medically necessary for a weight reduction program.; Note: Many/most Aetna benefit plans specifically EXCLUDE coverage of weight reduction medications, and specifically exclude services and supplies for weight reduction (check benefit plan descriptions for details); where excluded, the medical necessity criteria in this bulletin do not apply. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0039 — Weight Reduction Programs

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0039 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.