Brooklyn Mom Nadine Friedman Won Her Appeal After Aetna Called Her 9-Year-Old Son Ozzie’s $27,000 Ear Surgery ‘Cosmetic’

The word Aetna used to turn down Ozzie Roberts’ ear surgery was “cosmetic.” His parents, Nadine Friedman and Jared Roberts of Brooklyn, say the pain, redness and growth problems in their 9-year-old son’s right ear were anything but. This fall, after a months-long fight, an outside reviewer agreed with them, and Aetna agreed to cover the roughly $27,000 procedure, CBS New York reported.

Friedman told the station the win took far more than a stack of paperwork. It took a flexible job, time to document every step and what she described as becoming “a part-time insurance lawyer.”

An ear that hurt at night

Ozzie was born with Goldenhar syndrome, a rare condition that, according to the Cleveland Clinic, affects the development of the face and skull and shows up in roughly 1 in 3,500 to 5,000 births. Most affected babies have underdeveloped bones and muscles on one side of the face. Some children have one very small ear, others are missing an ear or have hearing loss, and the exact cause is unknown.

For Ozzie, the trouble centered on his right ear. His medical records link the condition to pain, redness and growth problems there, according to CBS New York. His father, Jared Roberts, described nights when the boy cried and screamed, something the family found hard to watch.

In February, doctors performed an ear-pinning surgery. The family says it worked.

The Cleveland Clinic says treatment depends on a child’s symptoms, and options can include hearing aids, speech therapy or surgery for a small ear, among others. For a family like Ozzie’s, that means medical decisions arrive one procedure at a time, and each can bring its own insurance question.

How a $27,000 bill became a coverage fight

The trouble began with the insurer. Aetna denied coverage for the roughly $27,000 procedure and labeled it cosmetic, even though Ozzie’s doctors wrote that it was “medically necessary,” CBS New York reported.

Aetna told the station that the doctor’s original billing code is typically used for cosmetic procedures and warranted further review. The company said it understood how hard health episodes are for families but declined an interview.

The disagreement, in other words, came down to a label. Ozzie’s doctors called the surgery necessary for his health, while the insurer’s reading of a billing code pointed toward appearance.

That back-and-forth lasted months. The family’s first step, an internal appeal directly to Aetna, did not change the answer.

The outside review that changed the answer

The next step was an external review, in which a state-appointed independent organization decides whether to reverse the insurer’s denial. In New York, the Department of Financial Services says a patient can file an external appeal when a plan denies a service as not medically necessary. The filing must come within four months of the plan’s final internal appeal decision. Plans may charge $25 per appeal, capped at $75 per plan year, and the fee is waived in cases of hardship and for enrollees in programs such as Medicaid and Child Health Plus.

A standard external appeal is decided within 30 days, and the department says the reviewer’s decision is binding on both the patient and the health plan. The page does not say whether denials labeled cosmetic qualify, and it directs people with questions to the department at (800) 400-8882.

In Ozzie’s case, the external appeal succeeded earlier this fall, and Aetna agreed to cover the surgery.

What the numbers say about appeals in New York

Friedman’s result is not unusual in the state. Researchers Ayesha Rahim of Brown University and Joseph Dov Bruch of Weill Cornell found that 52% of denials that reached external appeal in New York last year were reversed, CBS New York reported. Rahim said the finding shows most external appeals are overturned.

A separate analysis in JAMA, summarized by Healthcare Dive, looked at about 51,000 New York cases from 2019 to 2025 and found the overturn rate rose from 38% to almost 53%. Aetna’s rate was roughly 40% to 50%, similar to Anthem and UnitedHealthcare. The study covers only New York and did not examine why rates differ.

Bruch told CBS New York that reversals could reflect human or technological error, ambiguous policy language or inappropriate insurer behavior. Eric Linzer, CEO of the New York Health Plan Association, said “the vast majority” of requested services are provided, and that insurers look at peer-reviewed evidence and specialty guidelines.

A push for a federal law

Friedman said the process was still a struggle even with outside help, and she is now pushing for federal legislation. The Ensuring Lasting Smiles Act would require group and individual health plans to cover medically necessary services for congenital anomalies or birth defects that primarily affect the appearance or function of the eyes, ears, teeth, mouth or jaw, while excluding cosmetic procedures, according to a press release from Sen. Tammy Baldwin’s office.

Baldwin and Sen. Joni Ernst reintroduced the bill in May 2025, with a companion in the House led by Reps. Kim Schrier and Neal Dunn. It remains a proposal, not law. Among the conditions its sponsors list are cleft lip and palate and microtia.

For now, families in New York have the external appeal, and Friedman says it worked for her son only because she could give it the time it demanded. Nonprofits and health care advocacy groups can help New Yorkers file appeals, according to CBS New York.

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This article was produced with AI assistance and edited for accuracy against the sources linked above.

Image: Tomasz Sienicki – Public domain/Wikimedia Commons