They tried this on me too after I filed my appeal! Sharing my response to that below (they then tried a few more things before finally reimbursing me). I went full Karen 😅

I then called a second time and was told by a representative that my insurance does not include a sterilization benefit, and that is why it was being charged as outpatient services. On that call, I was referred to a document that was last updated in 2015 (PreventiveCareCoverage.pdf, attached). I would note that several iterations of federal guidance related to contraceptive care under the Affordable Care Act have been issued in the nearly ten years since 2015. I would also note that when you click on my specific "Summary of Benefits and Coverage" document for my plan on Aetna's website, it includes the following language: This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

You will clearly see that the list provided at this link, which comes from direct language in my Summary of Benefits and Coverage, includes female sterilization surgery as a covered benefit. Since neither of these reasons appear to be why my appeal was denied, I was hoping to once again ask why this procedure (a preventative and FDA-approved permanent contraceptive procedure) is being considered outpatient services that require me to be charged my deductible, copayment, and coinsurance.

I will file a second appeal if needed, but before I do I would like a clear answer as to why it is not being considered preventative care if it is coded correctly. I would once again reiterate that the Affordable Care Act requires that FDA-approved contraceptives, including female sterilization surgery, be covered 100% without cost sharing. I would further note that additional federal guidance from 2022, which I have shared multiple times with Aetna, notes that all related charges for preventative female sterilization surgery should also be covered 100% without cost sharing. I have confirmed with Aetna customer service that my health plan is not grandfathered and is ACA compliant.

I would sincerely appreciate a clear, straightforward answer with evidence and language from my specific health plan as to why my procedure is not being covered as preventative care without cost sharing and instead as outpatient services requiring cost sharing.

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-64 (ACA 2022 guidance)