Peer review of acupuncture not substantitatedSeptember 24, 2014

Shirom Acupuncture, P.C. v Kemper Independence Ins. Co., 2014 NY Slip Op 51407(U)(App. Term 1st Dept. 2014)

“We agree that the peer review report relied upon by the defendant-insurer was insufficient to establish, as a matter of law, that the acupuncture services underlying plaintiff’s $2,175 no-fault claim lacked medical necessity. The report addressed the medical necessity of acupuncture services rendered to plaintiff’s assignor during a time frame prior to that covered by the bills sued upon here, with defendant’s peer reviewer basing his finding of a lack of medical necessity on narrow grounds, viz., the perceived vagueness of the provider’s initial acupuncture report and treatment notes. In such form, and since defendant’s peer reviewer stopped short of concluding that the assignor’s medical condition could never be shown to warrant further acupuncture treatments, his report cannot be read so broadly as to justify, without more, the denial of any and all future claims for acupuncture services rendered to the assignor. Thus, summary judgment dismissal of this claim was properly withheld.”

This one is interesting.  How many acupuncture cases have you seen where the insurance carrier denied all billing based upon a prior peer review?   I am surprised this was taken on appeal.  But what is interesting is that a peer review for an initial set of services can state broadly that all further services would not be medically necessary and the peer would (it appears) satisfy the initial burden of persuasion.

This case can definitely be used (with a proper peer review) to substantiate the denial of all pre-IME conservative therapeutic service.

2 Responses

  1. ALAN Klaus says:

    This is the proper decision. Any other outcome would have been ludicrous. A peer review cannot determine future services.

  2. The Hater says:

    Thank you for admitting the truth. Insurance companies look for reasons to deny claims not medical necessity. We’ve heard about the corporate practice of medicine.

    Here we have the lawyer practice of medicine: “Oh just stick this in your peer review and we can cut off all payments.”

    Jason there is a place in hell for you and the rest of the insurance company attorneys — except you already live in hell denying old lady’s claims to make a scheckle or two.

    Disgusting. The Hater could probably beat the shit out of the whole defense bar combined.

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