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Case Study: Successfully Appealing an Aetna Weight Loss Surgery Denial

Synopsis: Is gastric bypass covered by insurance? Does Aetna cover weight loss surgery? It should be covered, but in this case, a woman seeking approval from her insurance company for gastric bypass surgery was denied coverage because she had not been morbidly obese for two consecutive years. We appealed the denial and obtained an immediate reversal.

The Challenge: Appealing an Aetna Bariatric Surgery Denial

When it comes to weight loss surgery, Aetna, like many insurers, can require that the patient be morbidly obese for a certain length of time. That means a patient who has worked hard to lose weight through diet and exercise could see those efforts actually work against them.

Overview

A 43-year-old woman with a BMI of 47.4 (5’4″, 276 lbs.) was seeking approval for a Roux-en-Y (RNY) gastric bypass.

As required by her insurance carrier, Aetna, she had already completed a supervised diet and received her nutritional, psychological and medical clearances before her doctor submitted the preauthorization request for an RNY gastric bypass.

Despite the fact that she had some serious comorbid conditions, including GERD, degenerative joint disease in her weight-bearing joints, stress incontinence, and signs of developing type 2 diabetes, Aetna denied coverage for the surgery based on their determination that she had not been morbidly obese for two consecutive years. 

Like many people in her position, she went on diets, and had even succeeded in lowered her BMI to 38.8, which was not in the “morbidly obese” range, according to Aetna. Because she had dipped temporarily below the “morbidly obese” range, her insurance company claimed she did not qualify for weight loss surgery under their medical policy despite her current BMI of nearly 48.

Her surgeon attempted to help her by requesting a peer to peer review with Aetna’s Medical Director, but Aetna refused to change the decision. 

The Solution

The patient was devastated and didn’t know what to do. Referred to our office by her surgeon, she decided to retain our services and we went to work.

The Outcome

After obtaining her medical records, we analyzed her case and filed an appeal. Less than 30 days later, Aetna overturned their denial and approved her surgery.  She had her Roux-en-Y gastric bypass on August 31, 2012 and is doing wonderfully.