Why Trust This Analysis
This article is part of our ongoing medical necessity coverage, with 170 published articles analyzing medical necessity issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
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.
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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 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.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Medical Necessity Disputes in No-Fault Insurance
Medical necessity is the most common basis for no-fault claim denials in New York. Insurers hire peer reviewers to opine that treatment was not medically necessary, shifting the burden to providers and claimants to demonstrate otherwise. The legal standards for establishing and rebutting medical necessity — including the sufficiency of peer review reports, the qualifications of reviewing physicians, and the evidentiary burdens at arbitration and trial — are the subject of extensive case law. These articles provide detailed analysis of medical necessity litigation strategies and court decisions.
170 published articles in Medical Necessity
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a medical necessity matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
