New York mom faced a $27K bill after Aetna denied her 9-year-old son's surgery as 'cosmetic' — how she fought back

“A lot of the nights during the week, just midway through the night, [he was] just crying, screaming,” Friedman told CBS. “It was really tough to see.”

Roberts received surgery to fix his ear — but Friedman’s insurance provider, Aetna (which is owned by CVS Health), wouldn’t cover the cost. That left Friedman’s family stuck with almost $30,000 they shouldn’t have had to pay.

Here’s how Friedman successfully got Aetna to pay for the surgery — and what you can do if you’re facing an insurance bill you feel should have been covered.

Becoming a ‘part-time insurance lawyer’ to fight the denial

Roberts got ear-pinning surgery, a procedure that involves moving someone’s ears closer to their head. It’s a form of plastic surgery that some people get to improve their appearance. But for Roberts, the surgery was medically necessary.

Aetna still denied the claim, saying the procedure was cosmetic. Friedman appealed the decision and was again denied, even though Roberts’ doctors wrote Aetna telling them the surgery was needed.

“I would absolutely never do anything like this unless it absolutely impeded on his health and his life,” Friedman told CBS.

Aetna told CBS that Roberts’ “original submitted billing code is typically for coverage of a cosmetic procedure and warranted further review.”

Friedman isn’t alone. According to Muni Health, Aetna denied 22%, or one in five, in-network ACA marketplace claims in 2023 — just over the national average of 20%. That means Aetna denied over one in five in-network claims.

Eventually, the family filed for an external review with the state of New York. A third-party organization would look over the claim and decide whether or not to reverse the denial.

The external appeal worked. After months of working to get the denied claim repealed, Friedman would no longer have to pay for the surgery herself.

“Which is great, but it’s only because I have a flexible job, time to document these things,” Friedman told CBS. “In the end, you have to become, like, a part-time insurance lawyer, basically, to do these things.”

When asked for comment, a CVS spokesperson referred Moneywise to the trade industry group AHIP. AHIP told Moneywise that claims denials are generally reviewed by a clinical or claims processing team member, but it was unable to speak about the specifics of Aetna policy.

How you can get outside help to fight denied health insurance claims

If you’ve tried to appeal a denied claim with your health insurance without luck, a way forward is possible.

Your next best step might be to file an external review, as Friedman ultimately did. If your claim was denied due to one of these reasons, you qualify:

• Your insurer made a medical judgement your doctor disagreed with, such as Friedman’s case;
• Your insurer denied the claim because it said the treatment was experimental; or
• Your insurer said you lied or left out information when you applied for coverage.

If you qualify, you’ll need to file within four months of your insurer’s final decision.