
Medical Policies
NY External Appeals
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)
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...