Key Takeaway
Nassau County court rules neurologists cannot challenge chiropractor MRI orders without proper foundation. Important ruling for Long Island and NYC medical providers.
No-fault insurance cases in Long Island and New York City frequently involve complex medical testimony disputes. When insurance companies challenge the medical necessity of diagnostic procedures like MRIs, the expertise and qualifications of their reviewing physicians become crucial factors in court proceedings. A recent Nassau County District Court decision highlights a critical issue that affects medical providers and patients throughout the New York metro area.
Court Ruling on Neurologist’s Testimony Scope
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co., 2010 NY Slip Op 50053(U)(Dis. Ct. Nassau Co. 2010)
“When a doctor testifies outside his area of expertise, the party calling the doctor must lay a foundation establishing the doctor is familiar with the generally accepted practice in the area in question to lay a proper a foundation for the expert’s opinion. Shectman v. Wilson, -A.D.3d-, 2009 WL 4674047 (2nd Dept. 2009); and Geffner v. North Shore University Hosp., 57 AD3d 838 (2nd Dept. 2009).
State Farm had a neurologist perform the peer review and called a neurologist to testify the cervical and lumbar MRIs ordered by a chiropractor were not medically necessary. Even though the parties stipulated Dr. Seliger was an expert, his field of expertise is neurology not chiropractics. State Farm did not establish Dr. Weiland, the peer reviewer, or Dr. Seliger, the re-peer, were familiar with generally accepted chiropractic practices or the generally accepted reasons why a chiropractor would order a patient to have a cervical or lumbar MRI. Therefore, Dr. Weiland’s peer review report and Dr. Seliger’s testimony are insufficient to rebut the presumption of medical necessity that attaches to a timely filed no-fault claim.”
I have never been an “I told you so” kind of person, but I think those of us who have followed the law since Geffner was announced last year saw this one coming. On various conference calls and discussions that I have had with other defense counsel, I was given the common refrain that as long as a doctor of a “higher specialty” was used, the peer report or IME would always be proper. The defense counsel would then point to the DOI’s 2004 opinion letter where the Department approved of the higher specialty rule. Yet, as we all know, issues involving evidence and admissibility of certain evidence are questions solely within the province of the Court.
Also, I recall a particular defense attorney who I spoke with at a recent conference who insisted that the higher specialty rule would always prevail in these situations.
Implications for Long Island and NYC Medical Providers
This decision has significant ramifications for medical providers throughout Nassau County, Suffolk County, and the five boroughs of New York City. The ruling establishes that insurance companies cannot simply rely on any licensed physician to challenge medical necessity determinations made by specialists in different fields.
Understanding Medical Necessity in No-Fault Cases
The Foundation Requirement
Courts now require a proper foundation when experts testify outside their area of expertise. This means insurance companies must demonstrate that their reviewing physicians understand the generally accepted practices within the specific specialty that ordered the treatment or diagnostic procedure.
Impact on Chiropractic Care
This ruling is particularly significant for chiropractors practicing in Long Island and New York City. When a chiropractor orders an MRI for spinal evaluation, a neurologist reviewing that decision must demonstrate familiarity with chiropractic standards and practices, not just neurological protocols.
Precedential Value and Future Applications
The Elmont Open MRI decision builds upon the foundation established in Geffner v. North Shore University Hospital, creating a more robust framework for challenging inadequate peer reviews. This trend suggests courts are becoming increasingly protective of the presumption of medical necessity that attaches to timely no-fault claims.
Strategic Considerations for Medical Providers
Documentation Best Practices
Medical providers should maintain detailed records explaining their diagnostic reasoning, particularly when ordering expensive procedures like MRIs. This documentation becomes crucial evidence when insurance companies challenge medical necessity.
Understanding Peer Review Limitations
Providers should be aware that peer reviews conducted by physicians outside their specialty may be vulnerable to legal challenge, especially when proper foundations are not established.
Frequently Asked Questions: Expert Testimony in No-Fault Cases
Q: Can a neurologist review a chiropractor’s treatment decisions?
A: Yes, but the insurance company must establish that the neurologist is familiar with generally accepted chiropractic practices and the reasons why chiropractors order specific diagnostic tests.
Q: What is the “higher specialty rule”?
A: This was a DOI-approved practice allowing specialists to review treatment by general practitioners or other specialists. However, courts maintain authority over evidence admissibility regardless of DOI opinions.
Q: How does this affect medical necessity determinations?
A: The ruling strengthens the presumption of medical necessity for timely no-fault claims by requiring proper expert foundations before that presumption can be rebutted.
Q: Does this apply to all types of medical procedures?
A: The principle applies broadly – any expert testifying outside their area of expertise must demonstrate familiarity with the relevant specialty’s practices.
Q: What should providers do if their treatment is challenged by an inappropriate peer reviewer?
A: Consult with experienced no-fault attorneys who can challenge the adequacy of the peer review foundation and protect your right to reimbursement.
Protecting Your Rights in No-Fault Disputes
If you’re a medical provider in Long Island or New York City facing insurance company challenges to your treatment decisions, it’s essential to work with attorneys who understand these evolving legal standards. The experienced legal team at JTNY Law has successfully handled thousands of no-fault cases and stays current with the latest developments in New York insurance law.
Don’t let inadequate peer reviews prevent you from receiving proper reimbursement for medically necessary services. Our attorneys know how to challenge improper expert testimony and protect your practice’s interests.
Need legal assistance with a no-fault insurance dispute? Call us today at 516-750-0595 for a consultation with our experienced no-fault litigation team.
Related Articles
- Why Conclusory Affidavits Fail: Building Strong Opposition to Medical Necessity Summary Judgment Motions
- Understanding Foundation Requirements in Medical Malpractice Expert Testimony
- How an Expert Becomes Competent to Testify About Standard of Care in Specific Practice Areas
- The Convergence of Medical Malpractice and No-Fault Litigation: Understanding Cross-Practice Legal Principles
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2010 decision, New York’s no-fault regulations have undergone multiple revisions, including amendments to peer review requirements, expert testimony standards, and medical necessity determination procedures. The fee schedules and procedural rules governing MRI authorizations and expert witness qualifications may have been substantially modified. Practitioners should verify current provisions under the updated Insurance Law Article 51 regulations and recent court interpretations of expert testimony requirements in medical necessity disputes.
