Aetna Covers $27,000 Ear Surgery After Denial Reversed
An external review overturned the insurer's cosmetic classification for a 9-year-old Brooklyn boy's ear-pinning procedure.
Updated on Nov. 6, 2026 in Insurance
Aetna agreed to cover a $27,000 ear-pinning surgery for 9-year-old Ozzie Roberts of Brooklyn after an external review overturned the insurer's denial. The insurer had classified the procedure as cosmetic, though the boy's doctors wrote that it was medically necessary.
Why it matters
The case shows how New York's external review process can reverse insurance denials that patients appeal internally. It also highlights disputes over whether congenital-related procedures are cosmetic or medically necessary.
Researchers found that 52% of denials reaching external appeal in New York State last year were reversed, against all denials that advanced to that stage. The overturned denial covered a $27,000 procedure, but the extraction does not show how many comparable cases remain under review.
The players
Aetna
Aetna is a major health insurer whose classification of the surgery as cosmetic was overturned on external review.
Nadine Friedman
Nadine Friedman is a Brooklyn mother advocating for federal legislation requiring coverage of necessary treatments for congenital anomalies.
New York Health Plan Association
The New York Health Plan Association is a trade group representing about 20 major insurers operating in New York.
The details
The family filed an external review after Aetna's internal appeal was rejected, and the review overturned the denial in the fall. The surgery itself was performed in February, before the decision was reached.
Timeline
February: Ozzie underwent ear-pinning surgery.
Earlier this fall: The external review overturned the denial and Aetna agreed to cover the cost.
Legal Context
The family's case is being used to advance the Ensuring Lasting Smiles Act, which would require coverage of necessary treatments for congenital anomalies. The outcome underscores how external review under New York's state process can overturn denials that internal appeals upheld.
Patients whose insurers deny procedures as cosmetic can request an external review in New York, which overturned a denial in this case. The reversal rate of 52% last year suggests that persistent appeals can succeed for some families facing similar claims.
The takeaway
Families denied coverage as cosmetic should document medical necessity from treating physicians and consider filing an external review. Persistence through the appeal process can change the outcome.
Further reading
Explore more on Insurance coverage disputes and how external appeals work for New York City patients.
Source note: This article includes information reported by CBS News.
