Key Takeaway
New York court reinforces Pan Chiropractic standard for medical necessity denials, requiring affirmed peer review reports with factual basis and medical rationale.
Understanding Medical Necessity Burdens in No-Fault Insurance Cases
In New York no-fault insurance law, medical necessity denials represent one of the most contentious battlegrounds between healthcare providers and insurance companies. When an insurer denies coverage for medical equipment or treatment, the legal framework requires a careful analysis of who bears the burden of proof and what evidence satisfies that burden.
The Pan Chiropractic decision established a crucial precedent for how courts evaluate medical necessity denials. Under this standard, insurance companies must submit more than mere conclusory statements—they need affirmed peer review reports that contain both factual foundations and clear medical reasoning. This requirement protects healthcare providers from arbitrary denials while ensuring that insurance companies can defend legitimate coverage decisions.
The burden-shifting framework is particularly important in summary judgment motions, where courts must determine whether sufficient evidence exists to proceed to trial. When insurers meet their initial burden with proper peer review documentation, the burden shifts to healthcare providers to present contradictory evidence. This dynamic significantly impacts litigation strategy and case outcomes, as a copy of a peer report is all that is needed to establish the initial showing.
Jason Tenenbaum’s Analysis:
Alur Med. Supply, Inc. v Clarendon Natl. Ins. Co., 2010 NY Slip Op 50700(U)(App. Term 2d Dept. 2010)
“Contrary to plaintiff’s contentions, once defendant submitted an affirmed peer review report that set forth a factual basis and medical rationale for its peer reviewer’s opinion that the medical equipment provided was not medically necessary, defendant established, prima facie, a lack of medical necessity for the equipment in question, shifting the burden to plaintiff to rebut defendant’s showing (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 [*2]NY Slip Op 51495 ).”
Key Takeaway
This decision reinforces the Pan Chiropractic standard, demonstrating its continued application across different types of medical necessity cases. For healthcare providers, this emphasizes the importance of maintaining comprehensive documentation and being prepared to present compelling contrary evidence when facing denials. Understanding these medical necessity reversals requires careful attention to the quality and specificity of peer review reports submitted by insurance companies.
Legal Update (February 2026): Since this 2010 post, New York’s no-fault insurance regulations have undergone multiple amendments, including revisions to medical necessity standards, peer review requirements, and documentation protocols. The regulatory framework governing burden of proof in medical necessity disputes may have been modified through subsequent Insurance Department regulations and judicial decisions. Practitioners should verify current provisions in 11 NYCRR 65 and recent case law interpreting the Pan Chiropractic standard.
