Aetna Insurance - WLS Benefits

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sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea); or

4.

Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

and

2. Member has completed growth (18 years of age or documentation of completion of bone growth); and

3. Member has attempted weight loss in the past without successful long-term weight reduction; and

4.

Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multidisciplinary surgical preparatory regimen):

1.

Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria:

1. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and

2. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least three consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and

3.

Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records;

or

2.

Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:

1. Consultation with a dietician or nutritionist; and

2. Reduced-calorie diet program supervised by dietician or nutritionist; and

3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and

4. Behavior modification program supervised by qualified professional; and

5.

Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)

and

5.

For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

2.

Vertical Banded Gastroplasty (VBG):

Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions:

1. Hepatic cirrhosis with elevated liver function tests; or

2. Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or

3. Radiation enteritis; or

4. Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or

5.

Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix).

Aetna considers VBG experimental and investigational when medical necessity criteria are not met.

3.

Repeat Bariatric Surgery:

Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

1. Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

2.

Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.

4.

Experimental and Investigational Bariatric Surgical Procedures:

Aetna considers each of the following procedures experimental and investigational because the peer reviewed medical literature shows them to be either unsafe or inadequately studied:

* Loop gastric bypass

* Gastroplasty, more commonly known as ?stomach stapling? (see below for clarification from vertical band gastroplasty)

* Sleeve gastrectomy

* Mini gastric bypass

* Silastic ring vertical gastric bypass (Fobi pouch)

* Intragastric balloon

* VBG, except in limited circumstances noted above.

*

LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above.

Cholecystectomy:

As a high incidence of gallbladder disease (28%) has been documented after surgery for morbid obesity, Aetna considers routine cholecystectomy medically necessary when performed in concert with elective bariatric procedures.

Notes:

Calculation of BMI:

*BMI is calculated by dividing the patient's weight (in kilograms) by height (in meters) squared:

BMI = weight (kg) * [height (m)]2

Note: To convert pounds to kilograms, multiply pounds by 0.45. To convert inches to meters, multiply inches by 0.0254.

or

For a simple and rapid calculation of BMI, please click below and it will take you to the Obesity Education Initiative.

*BMI = weight (kg) * [height (m)]2

See also CPB 039 - Weight Reduction Medications and Programs.