New York’s external-review process gives some patients a route to challenge an insurer’s final denial. Brooklyn mother Nadine Friedman used that process after Aetna refused to cover a $27,000 ear surgery for her 9-year-old son, describing the procedure as cosmetic despite his doctors’ view that it was medically necessary. The state review reversed the denial, and Aetna will cover the surgery, according to CBS News New York.
Friedman’s son, Ozzie Roberts, has Goldenhar syndrome, a condition that medical records say caused pain, redness and growth problems in his right ear, according to CBS News New York. Ozzie had ear-pinning surgery in February, which the station reported worked for him. Aetna initially denied coverage, calling the procedure cosmetic despite his doctors’ assessment that it was medically necessary.
From Insurer Appeal to State Review
Friedman and her husband, Jared Roberts, first appealed directly to Aetna, but the insurer upheld its denial, CBS reported. The couple then sought New York’s external review, in which an outside organization decides whether to reverse an insurer’s denial. Aetna told the station that the original billing code was typically used for cosmetic procedures and warranted further review.
The family learned earlier this fall that the external appeal had succeeded, CBS reported. Aetna declined an interview with the station but said in a statement that it recognizes the challenges health care episodes can pose for families.
Aetna's own clinical policy bulletin distinguishes between procedures it excludes as cosmetic and those it covers as medically necessary. The insurer states that its plans “exclude coverage of cosmetic surgery and procedures that are not medically necessary, but generally provide coverage when the surgery or procedure is needed to improve the functioning of a body part or otherwise medically necessary.” The same policy specifically notes that otoplasty to correct large or protruding ears is considered cosmetic when the surgery will not improve hearing. Aetna's documentation also says physicians requesting coverage may need to submit photographs, medical-necessity letters and chart records to support a claim.
Why the Appeal Process Is So Hard
Friedman told CBS she could pursue the drawn-out appeal because she had a flexible job and time to document the case. The family said the process was still a struggle, even with outside help. Nonprofits and health care advocacy groups assist New Yorkers with insurance appeals, the station reported.
New York State’s Department of Financial Services says patients may seek an external appeal when an insurer denies care as not medically necessary, experimental or investigational, or out-of-network. The department’s application materials indicate that requests generally must be filed within four months of a plan’s final adverse determination; patients should check the department’s current guidance for requirements.
How New York External Review Works
The state’s model plan language says a request is forwarded to a certified External Appeal Agent only if it meets the criteria, according to the New York State Department of Financial Services. The outside reviewer considers whether the insurer’s denial should be reversed. For filing steps and current requirements—including the general four-month deadline after a final adverse determination—patients should consult the department’s guidance.
Research cited by CBS suggests that many denials reaching external review are reversed. Ayesha Rahim of Brown University and Joseph Dov Bruch of Weill Cornell study state-appointed external reviewers; CBS reported that 52 percent of New York external appeals resulted in reversals last year. Rahim said a majority of external appeals are overturned, while Bruch said reversals could reflect human or technological errors, policy ambiguity, or inappropriate insurer behavior.
Insurers Push Back on the Narrative
The New York Health Plan Association, a nonprofit trade group representing about 20 major insurers statewide, offered a different framing. Eric Linzer, the association's CEO, said the vast majority of these services ultimately get provided, and that medical-necessity claims must align with peer-reviewed evidence and specialty society guidelines. Linzer added that providers can vary widely in how they approach particular services, which can complicate initial reviews.
Friedman's experience has pushed her toward advocacy. She is now backing the Ensuring Lasting Smiles Act, which would require insurers to cover necessary treatments for people with congenital anomalies or birth defects, according to the CBS report.
A Pattern Beyond One Family's Case
Aetna has faced scrutiny over cosmetic-versus-medical classifications in other disputes. In a separate case, Courthouse News Service reported that Aetna categorized facial feminization surgeries for transgender women as excluded cosmetic procedures and refused to cover them. A Connecticut federal judge ruled that Aetna’s blanket refusal to pay for the surgery violated the Affordable Care Act’s prohibitions against sex discrimination. Aetna appealed that ruling to the Second Circuit, arguing the plaintiffs’ claimed injuries trace back to their employers’ plan choices rather than Aetna’s own guidelines. In a separate development in that case, a March 8, 2026, preliminary injunction required Aetna to make individualized medical-necessity determinations for two plaintiffs, rather than categorically excluding their claims under CPB 0615, according to the U.S. District Court for the District of Connecticut order reproduced by Justia. The injunction applied only to those plaintiffs; it was separate from the Brooklyn family’s external appeal.
A separate case series listed in JAMA Internal Medicine says it is examining the clinical and administrative characteristics of insurance claim appeals, denials and decision reversals in New York State from 2019 to 2025, though the publicly available listing does not include specific findings or an overall reversal rate.
