External Appeals Searchable Archive
Database of closed NYS External Appeals that provides case summaries and appeal outcomes
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You may use the Categories to search by Diagnosis, Treatment, Health Plan, Appeal Type, Gender, Age Range, Decision Year, Appeal Agent or Case Number. The Search field below can be used to search for words that may appear in the text of the summaries, such as type of cancer or a drug name. Multiple Categories along with the Search field may be used simultaneously. While the Department's database includes decisions for appeals issued on and after May 31, 2019, it is possible that not all Categories will have a closed External Appeal case. For example, “cancer” will not display under the Diagnosis category until a summary is posted for that condition. |
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The Search field searches text within each appeal Summary and the Categories. Click Include References in Search to also search text in the References used to support the appeal decisions. |
When using the Search Summary and Reference field, the default is to search only Summaries. To include References in the search, click this box.
- 0Overturned
- 0Upheld
- 0Overturned in Part
Summary | References | ||||||||||
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Ears/ Nose/ Throat
|
Inpatient Hospital
|
Empire Healthchoice Assurance Inc.
|
Upheld
|
Medical necessity
|
Male
|
30-39
|
2021
|
IPRO
|
202102-134717
|
|
|
Central Nervous System/ Neuromuscular Disorder
|
Inpatient Hospital
|
Empire BlueCross BlueShield HealthPlus
|
Upheld
|
Medical necessity
|
Female
|
50-59
|
2021
|
IPRO
|
202102-134723
|
|
|
Genetic Diseases, Central Nervous System/ Neuromuscular Disorder
|
Inpatient Hospital
|
Metroplus Health Plan
|
Upheld
|
Medical necessity
|
Male
|
10-19
|
2021
|
MCMC, LLC
|
202102-134924
|
|
|
Dental Problems
|
Dental/ Orthodontic Procedure
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Male
|
10-19
|
2021
|
MCMC, LLC
|
202102-134957
|
|
|
Cardiac/ Circulatory Problems
|
Inpatient Hospital
|
Empire Healthchoice Assurance Inc.
|
Upheld
|
Medical necessity
|
Male
|
60-69
|
2021
|
IMEDECS
|
202102-135072
|
|
|
Blood Disorder
|
Inpatient Hospital
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Male
|
60-69
|
2021
|
IMEDECS
|
202102-135108
|
|
|
Central Nervous System/ Neuromuscular Disorder
|
Pharmacy/ Prescription Drugs
|
Fidelis Care New York
|
Overturned
|
Medical necessity
|
Female
|
60-69
|
2021
|
IPRO
|
202102-135169
|
|
|
Skin Disorders
|
Pharmacy/ Prescription Drugs
|
Aetna
|
Overturned
|
Medical necessity
|
Female
|
40-49
|
2021
|
MCMC, LLC
|
202102-135177
|
|
|
Cardiac/ Circulatory Problems
|
Advanced Imaging Services (Including PET/ MRI/ CT)
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Male
|
20-29
|
2021
|
MCMC, LLC
|
202102-135215
|
|
|
Genitourinary/ Kidney Disorder, Ears/ Nose/ Throat
|
Inpatient Hospital
|
Healthfirst Inc.
|
Upheld
|
Medical necessity
|
Female
|
50-59
|
2021
|
MCMC, LLC
|
202102-135428
|
|
|