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Medical Policies

0A - Spinal Fusion and Decompression

UHC (United)

Vaccines

UHC (United)

Vertebral Body Tethering for Scoliosis

UHC (United)

Upper Extremity Myoelectric Prosthetic Devices

UHC (United)

Vagus and External Trigeminal Nerve Stimulation

UHC (United)

Video Electroencephalographic (vEEG) Monitoring and Recording

UHC (United)

NY External Appeals

202305-163101

Fidelis Care New York

2023

Essential Plan

Upheld

Medical necessity

Categories:

Genitourinary/ Kidney Disorder

Inpatient Hospital

Case:

Diagnosis: Kidney stone
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission

202305-162738

Fidelis Care New York

2023

Essential Plan

Overturned

Medical necessity

Categories:

Central Nervous System/ Neuromuscular Disorder

Surgical Services

Case:

Diagnosis: Sleep Apnea
Treatment: Outpatient Procedure (nerve stimulation 64582 x 1)
The insurer denied: Outpatient Procedure (nerve stimulation 64582 x 1)

202308-166068

Healthfirst, Inc.

2023

Medicaid

Upheld

Medical necessity

Categories:

Respiratory System

Inpatient Hospital

Case:

Diagnosis: Community-acquired pneumonia.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.

202308-166051

Healthfirst, Inc.

2023

Medicaid

Upheld

Medical necessity

Categories:

Dental Problems

Dental/ Orthodontic Procedure

Case:

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.

202308-166651

Navitus Health Solutions

2023

Essential Plan

Overturned

Medical necessity

Categories:

Immunologic Disorders

Pharmacy/ Prescription Drugs

Case:

Diagnosis: Refractory Relapsing Granulomatosis with Polyangiitis
Treatment: Tavneos
The insurer denied Tavneos.

202307-165289

Aetna

2023

EPO

Upheld

Formulary Exception

Categories:

Digestive System/ Gastrointestinal

Pharmacy/ Prescription Drugs

Case:

Diagnosis: GERD (gastroesophageal reflux disease) and hiatal hernia
Treatment: Formulary exception for Dexlansoprazole Delayed-Release
The insurer denied: Formulary exception for Dexlansoprazole Delayed-Release

202305-162807

VNSNY CHOICE Health Plans

2023

Managed Long Term Care

Overturned

Medical necessity

Categories:

Respiratory System, Central Nervous System/ Neuromuscular Disorder

Home Health Care

Case:

Diagnosis: Chronic obstructive pulmonary disease (COPD), Dementia.
Treatment: Increase Personal Care Services to 24 Hours per Day (Split Shift) (Two 12 Hour Shifts) 7 Days a Week totaling 168 Hours.
The insurer denied Increase Personal Care Services to 24 Hours per Day (Split Shift) (Two 12 Hour Shi...

202305-162726

Fidelis Care New York

2023

Medicaid

Overturned

Medical necessity

Categories:

Orthopedic/ Musculoskeletal

Pain Management

Case:

Diagnosis: Back Pain
Treatment: Pain Injection
The insurer denied the pain injections.

202308-166060

Healthfirst, Inc.

2023

Medicaid

Upheld

Medical necessity

Categories:

Respiratory System

Inpatient Hospital

Case:

Diagnosis: Pleural Effusion
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission

202308-166049

Metroplus Health Plan

2023

Medicaid

Overturned

Medical necessity

Categories:

Dental Problems

Dental/ Orthodontic Procedure

Case:

Diagnosis: Malocclusion.
Treatment: D8080 braces; D8670 monthly visit x 8.
The insurer denied coverage for D8080 braces; D8670 monthly visit x 8.

202307-165295

Healthfirst, Inc.

2023

HMO

Overturned

Formulary Exception

Categories:

Skin Disorders

Pharmacy/ Prescription Drugs

Case:

Diagnosis: Psoriasis vulgaris
Treatment: Tremfya
The insurer denied coverage for Tremfya

202304-161721

Healthfirst, Inc.

2023

Medicaid

Upheld

Medical necessity

Categories:

Orthopedic/ Musculoskeletal

Inpatient Hospital

Case:

Diagnosis: Gout
Treatment: Inpatient Admission
The insurer denied the inpatient admission.

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