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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. |
References: |
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. |
Export all data by year (Excel)
When using the Search Summary and Reference field, the default is to search only Summaries. To include References in the search, click this box.
Coverage Type | Summary | References | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Substance Abuse/ Addiction
|
Substance Abuse: Inpatient
|
United Healthcare Plan of New York
|
Overturned
|
Medical necessity
|
HMO |
Male
|
40-49
|
2019
|
IPRO
|
201809-110342
|
|
|
Blood Disorder
|
Home Health Care
|
Healthfirst Inc.
|
Upheld
|
Medical necessity
|
Medicaid |
Male
|
70-79
|
2019
|
MCMC, LLC
|
201810-110716
|
|
|
Digestive System/ Gastrointestinal
|
Surgical Services
|
Excellus
|
Upheld
|
Medical necessity
|
Indemnity |
Male
|
50-59
|
2019
|
IMEDECS
|
201810-111285
|
|
|
Cardiac/ Circulatory Problems
|
Inpatient Hospital
|
Metroplus Health Plan
|
Upheld
|
Medical necessity
|
HMO |
Female
|
60-69
|
2019
|
IMEDECS
|
201812-112688
|
|
|
Substance Abuse/ Addiction
|
Substance Abuse: Inpatient
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Medicaid |
Female
|
40-49
|
2019
|
IMEDECS
|
201902-113919
|
|
|
Substance Abuse/ Addiction
|
Inpatient Rehabilitation
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Medicaid |
Male
|
50-59
|
2019
|
IMEDECS
|
201902-114093
|
|
|
Substance Abuse/ Addiction
|
Substance Abuse: Inpatient
|
United Healthcare Plan of New York
|
Overturned
|
Medical necessity
|
HMO |
Male
|
30-39
|
2019
|
IPRO
|
201902-114307
|
|
|
Orthopedic/ Musculoskeletal, Skin Disorders
|
Pharmacy/ Prescription Drugs
|
Fidelis Care New York
|
Upheld
|
Medical necessity
|
Medicaid |
Female
|
50-59
|
2019
|
IPRO
|
201902-114344
|
|
|
Orthopedic/ Musculoskeletal
|
Inpatient Hospital
|
Healthfirst Inc.
|
Upheld
|
Medical necessity
|
Medicaid |
Female
|
60-69
|
2019
|
IPRO
|
201902-114385
|
|
|
Substance Abuse/ Addiction
|
Substance Abuse: Inpatient
|
United Healthcare Plan of New York
|
Overturned
|
Medical necessity
|
HMO |
Male
|
20-29
|
2019
|
IPRO
|
201902-114419
|
|
|
The Department of Financial Services makes every effort to post accurate and reliable external appeal information. However, it does not guarantee or warrant that the information provided on this website is complete, accurate, or up-to-date. This database is provided solely for informational purposes and is intended to provide general information related to past external appeal decisions. The Department assumes no liability for the access to or your reliance upon any of the information provided. The Department assumes no responsibility for any error, omission, or other discrepancy in the database. Despite any similarities, your own medical condition may differ from that in any given case contained within this database. The Department makes no claims, promises or guarantees that using the information from this database will impact or otherwise result in a positive outcome for any pending or future external appeal application. All external appeal cases are specific to each individual and include many variables that affect the outcome of a particular case.