UPDATE! Aetna Revises its Clinical Policy Bulletin on Bariatric Surgery

Published in August 2014 Issue             

From ASMBS Insurance Committee -- Matthew Brengman, MD, Committee Chair

Matthew Brengman, MD

The Aetna Obesity Surgery policy has been updated with revisions. The clinical highlights are noted in his article.

Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met.

For Adults greater than 18 years of age:

  1. BMI greater than 40
  2. BMI greater than 35 in conjunction with any of the following severe comorbidities:

  1. Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults)

  2. Coronary heart disease, with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction)

  3. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes)

  4. Type 2 diabetes mellitus

This Clinical Policy Bulletin (CPB) strictly defines the comorbidities for use of bariatric surgery with a BMI less than 40. Note the new requirements for objective diagnostic studies for the diagnosis of coronary heart disease. The CPB is also revised to eliminate a 2-year history of obesity. The requirement now reads “a history of persistent obesity.”

Aetna again requires pre-surgical physician directed weight loss. This can either be a 3-month multi-disciplinary pre-surgical program, or 6-month physician directed programs. The detailed requirement and documentation requirements are within the 38-page policy linked to above. Of note, the 6-month program does not have to be consecutive. However, one of the interventions must be documented at least 3 months in duration and the 6 months must occur within 2 years of precertification (i.e. two 3-month interventions 6 months apart would now qualify). In addition, precertification can be sought prior to the completion of 6 months, as long as the 6 months will have been completed prior to the authorized date
of the surgery.

Repeat Bariatric Surgery is comprehensively addressed.

1. “Aetna considers removal of a gastric band medically necessary when recommended by the
     member's physician.”

2. “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 any of the following medical necessity criteria:

  1. Conversion to a sleeve gastrectomy, RYGB or BPD/DS is considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 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, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy anastomosis is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

  3. Replacement of an adjustable band is considered medically necessary if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments

The requirements for recurrent and persistent obesity mirror the conclusions of the ASMBS task force on revision or reoperative bariatric surgery.

This policy comprehensively allows operative revision of gastric bypass, gastric band and gastric sleeve. In addition, the policy allows for gastric band conversions and replacements.

Most other procedures are excluded as investigational. This includes, but is not limited to:

  • Band over Bypass
  • Band over Sleeve
  • Greater Curve Plication (LGCP)
  • All endoluminal therapies including Stomaphyx, Overstitch, and Endo-barrier (all listed by name)
  • Use of gastric bypass for gastroparesis, infertility and GERD in non-obese individuals

Overall, the policy is well written and supported by a long, but dated, bibliography. Please note the changes as highlighted in the article.