Aetna HMO IOQ Denial


Aug 18, 2023
Hello everyone!

I'm new to this forum and was looking for any help or advice. Here's my story...

I have an Aetna HMO through my employer that limits me to a cetain local hospital & their providers only. If I go to our other local hospital or one of their providers then my claims would be rejected for out of network. Anyways, I began my bariatric journey at the beginning of this year with the hospital that I'm limited to. The insurance coordinator for the weigh loss program called Aetna to verify if the services would be covered or not. Aetna informed them that bariatric services would not be covered for me because I did not meet one of their bariatric requirements and that was that I wasn't Type 2 diabetic. My employer plan through Aetna would only pay for bariatric services only if the insurer is Type 2 Diabetic not pre-diabetic. Aetna told the ins coordinator that my classes & surgery would be denied by them. Luckily I have great secondary insurance that does cover all bariatric service so we went ahead and scheduled all of my classes & tests.

I was scheduled for surgery on 8/28 and everything was going great until yesterday when I received a call from the weight management program advising me that Aetna was denying my preauthorization because my hospital was not one of their approved IOQ/Center of Excellence facilities. They completely left out that I was being denied because I was not Type 2 diabetic which was what they informed my hospital months ago before I started this journey.

After some back and forth Aetna revealed that my employer had just updated the bariatric services clause in our insurance on 8/1/23 to remove the Type 2 Diabetic requirement so now I would be eligible for 100% coverage through Aetna which is great but now they're saying that I need to go to one of their IOQ facilities after going through 6 months of the program with my hospital.

My issue is is that Aetna HMO limits me to my hospital and their IOQ facilities would be considered out of network for me. They then told me that because of this my bariatric surgery at one of their IOQs would also be rejected!!!!

I spoke to my surgeon's benefit coordinator and she advised me that because my employer & Aetna both changed the bariatric services clause in my insurance and they are now saying I'm covered 100% but that services & surgery need to be done at an IOQ facility, she can no longer submit for preauthorization through my secondary insurance even though my secondary has been paying for all of these services for the past 6 months. She said that if they would've rejected my preauth for the Type 2 Diabetes clause that was in place when I started the program then she would've been able to submit the preauth to my secondary because Aetna was essentially saying that I did not have bariatric coverage based of me not being diabetic.

So now my surgery is cancelled.

Aetna is saying that I have 100% bariatric coverage but I can't use my hospital because they are not one of their IOQ facilities but Aetna limits me to only using this specific hospital as it's in network with them.

Aetna is also saying that if I do go through one of their IOQs then I would be rejected because all of their IOQs are out of network for me.

My hospital is telling me that because Aetna is denying my preauth only because they're not an IOQ, that their hands are tied now and they can't submit preauth to my secondary because Aetna is technically saying I have 100% bariatric coverage through them and in order for them to pay I would have to use one of their IOQs even though Aetna has already made it clear that they will not cover my surgery at an IOQ because they'd be out of network.

I'm extremely upset & frustrated by all of this and have cried for hours trying to make sense of all of this. I have a primary insurance (Aetna HM0) that now covers bariatric services 100% to non-diabetics & pre-diabetics but will not cover the services for me now because my dictated hospital is not one of their IOQs and their IOQs are out of network. I have a wonderful secondary ins that will & has been covering my bariatric services but now my hospital cannot submit to them because of Aetna. So I basically have 2 insurance that provide 100% bariatric coverage but I can't utilize any of them to cover my surgery because of Aetna.

Has anyone ever heard of such craziness or experienced anything similar? Does anyone have any advice for me? Any suggestions are welcome. I just want to finally get this surgery and get my health on track.
I convinced Aetna to do things my way for a surgery our daughter needed. But that was long ago and in CA.

we are INCREDIBLY fortunate to have both DianaCox and Larra on board and THEY are actual experts on this type of nonsense.

You may “meet them” soon.

And welcome!

What state are you in? I’m trying to first figure out who you might get to act as an ombudsman to most quickly coordinate your coverage. My first thought is that you should have the option under a continuation of coverage theory to be able to complete the months-long program you already completed the pre-op requirements for in preparation for surgery under the prior coverage.

I’m confused about one other thing - if you use the Aetna coverage, can you get the same surgery? The same surgeon? If yes, is it only the fact that the hospital is not in-network? Can your current surgeon use in the-network hospital?
Hi DianaCox! I live and work in PA. My surgeon & hospital are in-network with my Aetna Custom HMO but they are not an Aetna IOQ/Center of Excellence.

I was on the phone with Aetna this morning for about 2 hrs and the representative as well as the pre certification specialist, her supervisor, & manager have never encountered a situation like mine. They were all baffled but what the preauthorization manger advised the preauthorization specialist to do was to file a request for a network deficiency exception.

The network deficiency exception works by allowing the patient to receive services at a facility closer to home if there is not an in-network IOQ/Center of Excellence with 50 miles of their home. All of the ones suggested to me were 50+ miles from me & would be out of network.

The catch is is that network deficiency exceptions are usually only done if the patients hospital & surgeon are out of network with Aetna which mine are in network as this hospital & it's providers are the only hospital that my Aetna HMO allows me to receive services from. This is why the Aetna representatives I spoke to where just as confused and flabbergasted as I was.

They said that these exceptions are almost always approved but since my situation is extremely unique that they can't guarantee that their medical director will approve it. It can take up to 15 days for review and to receive an approve/denial response from Aetna. So now it's a waiting game...

If it is denied then my only recourse would be to file an appeal.
No words of advice, but plenty of good wishes.

Years ago, the coverage manual issued by my employer outlined the criteria for WLS. I qualified and started things off. Surprise, surprise, I was denied. I took my case to corporate HR. I was told if I was dissatisfied, I could look for employment elsewhere. Angry doesn't even begin to describe my feelings. My silver lining was that three years later, I definitely was qualified. Had I been approved the first time, I would have gotten the RNY. As it was, I got the DS. I'm not knocking the RNY, but the DS was the better option for me.

Again, best wishes. This is a great forum for advice and venting.
Thank you so much k9ophile!

It's absolutely insane how these employer issued insurances outline the guidelines for WLS and you can meet every single one but they can turn around and deny you. And how absolutely disgusting of corporate HR to respond in that manner! They should be ashamed of how unprofessional they were.

I'm happy that you eventually were able to get approved and have the surgery even if it was 3 years later. I hope that it doesn't take me that long though as more medical issues are popping up the older I get.

Just my luck that my employer decided to remove the Type 2 diabetes requirement the same month of my surgery. That requirement had been in place for nearly 7 years making bariatric services unavailable to alot of the employees. They couldn't have waited to remove it on Sept 1st? Lol.

I'm glad that it's finally gone though but now we employees that have the Aetna Custom HMO have another battle on our hands on how to get the WLS & classes covered if we cannot get it done at our in-network non-IOQ hospital & providers. I will gladly lead this battle if it means helping others gain a healthier lifestyle & improve their quality of life.
I'm so glad things seem to be going forward (curse these companies!) and hope to hear you got the surgery.

Thanks Jackie! Yes these insurance companies are the worst. I hate they mandate what we can & can't have done based on their policies especially when we pay an arm & a leg for their coverage. Smh.

I'm trying to stay positive and praying that the medical director approves this exception and we can reschedule my surgery soon.
Thanks Jackie! Yes these insurance companies are the worst. I hate they mandate what we can & can't have done based on their policies especially when we pay an arm & a leg for their coverage. Smh.

I'm trying to stay positive and praying that the medical director approves this exception and we can reschedule my surgery soon.
Part of it is what the employer is willing to pay for. But if they pay for any type of Bariatric surgery, they should be forced to pay for all of them.
I completely agree Southernlady.

Ages ago my employer had it that employees could get bariatric services but they completely removed it from our insurance approximately 17 yrs ago. Then they quietly added it back onto the insurance 6 yrs ago with the stipulation that you HAD to be Type 2 diabetic in order for them to cover the services no ands, ifs, or buts. And now as of 8/1/23 they quietly decided to completely removed that requirement. But look how that's working out for me. Ha!
Hello everyone!

Quick in the mail I received an authorization letter from my secondary insurance stating that they are approving me for surgery which we all knew that they would. Still waiting on my primary...this is exhausting.

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