Key Takeaway
Learn the evidence standards for challenging medical necessity in NY no-fault insurance cases. Expert analysis from Long Island personal injury attorney.
Understanding Medical Necessity Evidence Standards in Long Island No-Fault Cases
In the complex world of New York no-fault insurance law, determining what constitutes sufficient evidence to challenge or support medical necessity findings is crucial for both healthcare providers and injured patients on Long Island and throughout the New York City area. A recent Appellate Term decision has begun to clarify these standards, offering important guidance for personal injury attorneys and medical providers navigating these disputes.
The Appellate Term’s First Foray into Medical Necessity Evidence
In an indiscreet case which garnered a “u” cite, the Appellate Term, Second Department made its first foray into determining what evidence is sufficient to raise an issue of fact as to a service’s medical reasonableness in opposition to a well supported peer review. The case on point is Park Slope Med. & Surgical Supply, Inc. v New York Cent. Mut. Fire Ins. Co. 2009 NY Slip Op 50441(U)(App. Term 2d Dept. 2009). The pertinent portion of the opinion went as follows:
“n response to defendant’s cross motion, plaintiff submitted an affidavit from Dr. Shapiro in which he stated that he disagreed with the peer review report and affidavit furnished by defendant because he concluded that the supplies provided were medically necessary. Since the affidavit of Dr. Shapiro demonstrated the existence of an issue of fact as to medical necessity”
It bears in mind that the “Dr. Shapiro” affidavit is boilerplate in nature, having seen a few of them. Yet, under the circumstances of this case, I cannot say the court was wrong in its holding.
The Context Behind the Decision
Assume for argument sake that Defendant failed to annex the documents his expert relied upon in forming his file based review. This is probably a valid assumption knowing what these motions tend to look like. In this instance, the Court should have found that Defendant did not meet its burden, and should have actually granted Plaintiff summary judgment. A peer report in opposition to a summary judgment motion that does not disclose the peer documents the reviewer relied upon simply fails to raise a triable issue of fact. Yet, until the Appellate Term addresses that issue, it is fair to say that the Court really did not have a choice but to find that Plaintiff raised an issue of fact. Between the lines, the court was asking how a Plaintiff could honestly oppose a file review without the file? Hopefully, the Court in the future will cite to Cariddi v. Hassan and skip the step of finding a medical provider’s conclusory affidavit to be sufficient to oppose a non-supported peer report.
I suspect that this is just the beginning of the development as to this discreet area of no-fault law.
The Broader Implications for Summary Judgment Practice
I would add this remark. The trend in New York practice has been to transform summary judgment motions from the traditional of “issue finding” into an exercise in “issue determination”. In other words, the courts used to deny summary judgment motions should there be a specter of a factual issue lurking somewhere. Now, the motion court will determine the merits of the issue on a motion for summary judgment.
This above trend is remarkable since every lower court decision that discusses an SJ motion always cites to the Court of Appeals cases, which hold that even the specter of a triable issue of fact should defeat a summary judgment motion. Shakespearean overtones I suspect – appearance verses reality.
But in the modern realities of life, the courts are telling the litigants that if you want a plenary trial, you need to earn it. In no-fault we had this shoved down our throats through “Dan Medical” and “Contempt v. Geico” prior to “Delta v. Chubb” and “St. Vincent v. Geico.” In the analogous 5102(d) land, “Toure” and “Pommels” proved this point too well. The list goes on and on…
Thus, we shall see how the lack of medical necessity jurisprudence develops. I just hope it does not suffer the same inconsistencies that we have found in the “EUO” default contexts.
Practical Implications for Long Island Healthcare Providers
For medical providers and healthcare facilities serving Nassau County, Suffolk County, and the greater New York City area, this decision provides both opportunities and challenges:
1. The Double-Edged Nature of Boilerplate Affidavits
While the court accepted Dr. Shapiro’s relatively conclusory affidavit as sufficient to create an issue of fact, healthcare providers should not rely solely on boilerplate language. The decision likely reflects the court’s recognition that the defendant insurer failed to properly support its peer review with underlying documentation.
2. Strategic Considerations for Medical Necessity Disputes
When facing peer review-based denials, providers should:
- Examine whether the insurer’s motion includes the actual medical records reviewed by the peer reviewer
- Challenge motions that rely solely on peer review conclusions without supporting documentation
- Prepare substantive affidavits that address specific medical findings rather than general conclusions
3. The Evolving Standard of Evidence
This case suggests that courts are grappling with the appropriate evidentiary standards in medical necessity disputes. The tension between accepting conclusory affidavits and requiring substantive medical evidence reflects broader challenges in no-fault litigation.
Impact on Personal Injury Practice in New York
For personal injury attorneys representing accident victims in Long Island and New York City, understanding these evidence standards is crucial when dealing with no-fault insurance disputes that affect their clients’ access to medical care.
The Connection to Broader No-Fault Issues
This decision fits within the larger pattern of New York courts requiring more substantive evidence in no-fault disputes. Just as courts have become more demanding in EUO (Examination Under Oath) default cases and 5102(d) serious injury threshold determinations, medical necessity disputes are seeing increased scrutiny of evidence quality.
Learning from Related Case Law
The reference to cases like “Dan Medical,” “Contempt v. Geico,” “Delta v. Chubb,” and “St. Vincent v. Geico” demonstrates the interconnected nature of no-fault jurisprudence. Each area of no-fault law has seen similar evolution toward requiring parties to “earn” their right to trial through more substantive evidence presentations.
Future Developments in Medical Necessity Law
As this area of law continues to develop, several trends are likely to emerge:
1. Increased Documentary Requirements
Courts may begin requiring insurance companies to provide the actual medical records reviewed by peer reviewers, following the precedent established in Cariddi v. Hassan for different but analogous situations.
2. Higher Standards for Opposition Affidavits
While this case accepted a relatively conclusory affidavit, future decisions may require more detailed medical analysis to create genuine issues of fact.
3. Clearer Procedural Guidelines
The hope is that appellate courts will provide clearer guidance on evidentiary standards, reducing the inconsistencies that have plagued other areas of no-fault litigation.
Frequently Asked Questions
Q: What makes an affidavit sufficient to oppose a medical necessity challenge?
A: While this case accepted a conclusory disagreement with peer review findings, the best practice is to provide detailed medical analysis explaining why the services were necessary, referencing specific medical records and clinical standards.
Q: Can I challenge a peer review that doesn’t include the underlying medical records?
A: Yes, based on the Cariddi v. Hassan precedent and the reasoning in this case, peer reviews without supporting documentation may fail to meet the moving party’s prima facie burden.
Q: How does this affect my no-fault insurance coverage?
A: This decision may make it easier for medical providers to challenge insurance denials based on peer reviews, potentially improving access to necessary medical care for accident victims.
Q: What should healthcare providers do when facing peer review denials?
A: Providers should examine the insurer’s motion for completeness, challenge inadequately supported peer reviews, and prepare substantive medical affidavits that address specific clinical findings.
Q: How does this relate to other areas of no-fault law?
A: This decision reflects a broader trend in New York no-fault litigation requiring more substantive evidence across all dispute areas, from EUO defaults to serious injury determinations.
Contact a Long Island No-Fault Attorney
As medical necessity evidence standards continue to evolve, having experienced legal representation is essential for both healthcare providers and injured patients navigating no-fault insurance disputes. Whether you’re a medical provider facing peer review denials or an accident victim whose treatment is being challenged, understanding these evidentiary requirements can make the difference between winning and losing your case.
For experienced representation in Nassau County, Suffolk County, and throughout the New York metropolitan area, call 516-750-0595 to discuss your case. Our office stays current with developing no-fault jurisprudence and understands how to effectively challenge inadequately supported medical necessity denials while building strong evidentiary foundations for our clients’ cases.
Related Articles
- Why conclusory affidavits fail in medical necessity opposition motions
- How Geico’s medical necessity motions were denied due to boilerplate letters
- Effective strategies for peer review rebuttals in no-fault cases
- Why poorly drafted medical affidavits fail against insurance motions
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2009 post, New York’s no-fault regulations under Insurance Law § 5102 have undergone multiple amendments affecting medical necessity standards and evidence requirements. The fee schedules, peer review procedures, and documentation standards for challenging medical necessity determinations may have been substantially revised. Practitioners should verify current regulatory provisions and recent appellate decisions when evaluating medical necessity evidence standards.
