NEW YORK, N.Y., April 5 – A report released by the Insurance Department shows that there has been increased utilization of the states External Appeal Law, which allows New Yorkers to challenge and potentially overturn their insurer or health maintenance organizations (HMO) denial of coverage on the grounds that a procedure, treatment or piece of medical equipment is deemed experimental, investigational, or not medically necessary.

According to Superintendent Howard Mills, the report shows:

The External Appeal Program received, in 2004, a record number of consumer applications (2,321), a 29 percent increase over the previous high (1,803), which was set in 2003;

The overwhelming majority of external appeal applications are related to insurer or HMO denials based on medical necessity and deal with coverage for substance abuse treatment, diagnostic testing, surgical, mental health and inpatient services and coverage for durable medical equipment (e.g., a wheelchair, a neck brace);

The External Appeal Program ruled in favor of the consumer in 45 percent of the cases involving medical necessity denials in 2004, and in 51 percent of the instances in which consumers were denied coverage by an insurer or HMO on the grounds that a treatment was deemed either experimental or investigational.

Mills said, More New Yorkers are learning about the states External Appeal mechanism, and about 45 percent of the cases are being resolved in the consumers favor, giving more residents access to health care services that they might not have otherwise received.

The External Appeal Law in 1999. External appeals must be submitted to the New York State Insurance Department " either online or through the toll-free hotline (1-800-400-8882), within 45 days of a consumers receipt of a final adverse determination from their insurer or HMOs internal appeals division, or when an insurer or HMO waives the internal appeal process. Health insurers and HMOs are allowed to charge consumers $50 for each external appeal.