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AetnaCommercial · Coverage · Surgery · Bariatric Surgery, General Surgery, GastroenterologyMedium impact

Obesity Surgery (CPB 0157, reviewed 2026-07-21)

Effective date
Not stated in the notice
Identified
Aug 17, 2026

Summary

Aetna's Obesity Surgery policy (CPB 0157) sets when bariatric procedures are medically necessary. Roux-en-Y gastric bypass, laparoscopic adjustable silicone gastric banding, sleeve gastrectomy, biliopancreatic diversion with or without duodenal switch, SADI-S and SIPS qualify for adults 18 or older with a BMI of 40 or greater, or a BMI of 35 or greater with obstructive sleep apnea, coronary heart disease, medically refractory hypertension, type 2 diabetes or MASH, and for adolescents who have completed bone growth with a BMI over 40. Most Aetna HMO and QPOS plans exclude surgical treatment of obesity unless Aetna approves it, and vertical banded gastroplasty, endoscopic sleeve gastroplasty, intragastric balloons and AspireAssist are listed as experimental, investigational or unproven.

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What to do

Action · 5 steps
01Claims for these bariatric procedures need documentation in the medical record of a BMI measured before the preoperative preparatory program, and of any listed comorbidity when the BMI is 35 or greater.
02Members must have an intensive multicomponent behavioral intervention documented in the medical record, with records showing compliance with the program, and the program must include 12 or more sessions on separate dates and occur within 2 years prior to surgery.
03Members seeking bariatric surgery must be assessed by a qualified behavioral health clinician for psychosocial functioning, substance use disorders and maladaptive eating behaviors.
04Aetna considers routine liver biopsy during bariatric surgery not medically necessary in the absence of signs or symptoms of liver disease, routine cholecystectomy medically necessary when performed with elective bariatric procedures, and concurrent hiatus hernia repair incidental and not separately reimbursable.
05Most Aetna HMO and QPOS plans exclude these procedures unless Aetna approves them, and some Aetna plans exclude them entirely, so check benefit plan descriptions for details.

Codes mentioned

432844364443645437704377143772437734377443775438424384343845438464384743848438864388743888442024323643253E66.01E66.09E66.3E66.812E66.813E67.8K75.81K91.1K95.09K95.89R63.2R63.5Z46.51Z98.84Z68.54

Original notice

Obesity Surgery (CPB 0157, reviewed 2026-07-21)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesBariatric SurgeryGeneral SurgeryGastroenterologyCode 43284Code 43644Code 43645Code 43770Code 43771Code 43772Code 43773Code 43774Code 43775Code 43842Code 43843Code 43845Code 43846Code 43847Code 43848Code 43886Code 43887Code 43888Code 44202Code 43236Code 43253Code E66.01Code E66.09Code E66.3Code E66.812Code E66.813Code E67.8Code K75.81Code K91.1Code K95.09Code K95.89Code R63.2Code R63.5Code Z46.51Code Z98.84Code Z68.54

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