New Jersey Appellate Division discusses MUA

Prospect Medical, PC v. PLIGA,  2011 WL 2462643 (NJAD 2011)

“Prospect Medical submitted claims for $18,168.68 for three MUAs performed on July 8, 9, and 10, 2008. That claim was amended to $18,084.34 in the arbitration that followed in the National Arbitration Forum before a Dispute Resolution Professional (DRP). The DRP identified one of the issues in dispute in the arbitration as whether the MUAs performed were reasonable and medically necessary and further noted Prospect Medical’s argument “that none of the opinions of chiropractors should be considered since they are not medical doctors and Dr. Sivendra is a medical doctor.” The DRP then reviewed in detail the protocols and standards of the National Academy of MUA Physicians (NAMUAP) regarding the clinical justification, medical necessity, guidelines for determining the necessity and frequency of MUA, the protocols for performing serial MUAs, and parameters for determining MUA progress. Applying those standards to the evidence submitted, the DRP set forth her conclusions:

Based upon a preponderance of the record evidence, I find that Claimant has failed to sustain its burden that the MUAs performed on 07/08/08, 07/09/08, and 07/10/08 were reasonable or medically necessary. Claimant’s medical records are devoid of clinical indicators which might have established the need for MUAs pursuant to the guidelines set forth by the National Academy of MUA physicians. First, the patient was found to be at MMI from chiropractic care on 10/16/07 and said opinion was upheld on 12/31/07. Second, and most significantly, there is no record of any conservative chiropractic care being performed from October of 2007 through June 21, 2008 when the patient presented to Dr. Sivendra. Yet, the protocols require that manipulative procedures must have been utilized in the clinical setting during the two to six week period prior to recommending MUA. No explanation has been provided by Claimant for this significant gap without any chiropractic treatment or any other treatment. Third, there was absolutely no evidence that the patient was experiencing intractable pain and/or biomechanical dysfunction. Fourth, there was no evidence that there was any pain interfering with the patient’s life-style. Fifth, there was no indication of spinal adhesions. Sixth, there was no indication that the patient was unable to undergo conscious chiropractic manipulations due to pain or rigidity. Seventh, there was no suggestion that the patient was being considered for spinal surgery. Eighth, there is a lack of supportive documentation of the hips or shoulders during the initial course of chiropractic treatment with Dr. Zientak to justify MUAs to those areas. Ninth, when the patient presented to Dr. Sivendra on June 21, 2008, the patient had no complaints in the hips or shoulders and Dr. Sivendra did not perform any examination of the hips or shoulders. Finally, while Dr. Sivendra makes the broad statement that the patient had reached a plateau from treatment, there were no medical records submitted demonstrating such. In sum, the medical record evidence simply does not support the MUA services rendered based upon the accepted NAMUAP protocols and clinical justifications for MUAs. Based upon the foregoing, I find that Claimant has failed to sustain its burden that the MUAs performed on 07/08/08, 07/09/08, and 07/10/08 were reasonable or medically necessary by a preponderance of the evidence. Accordingly, the demand is denied in its entirety and there is no reason to address any of the other issues raised.”

“For the trial court to vacate the award based upon Prospect Medical’s argument, it would have had to find that the DRP committed “prejudicial error by erroneously applying law to the issues and facts presented for alternative resolution.” N.J.S.A. 2A:23A–13(c). However, the DRP correctly held Prospect Medical to its burden of proof and examined the record to determine that Prospect Medical failed to meet that burden. Although PLIGA did not refer the precertification request to a medical doctor, Prospect Medical’s claims were properly subjected to a medical necessity analysis, consistent with the Legislature’s “intent to discourage the performance of unnecessary medical services.”

“Prospect Medical filed a verified complaint and order to show cause, seeking to vacate the arbitration award and for the entry of an award of $18,084.34 plus interest and attorney’s fees, alleging the DRP committed prejudicial error.”

“For the trial court to vacate the award based upon Prospect Medical’s argument, it would have had to find that the DRP committed “prejudicial error by erroneously applying law to the issues and facts presented for alternative resolution.” N.J.S.A. 2A:23A–13(c). However, the DRP correctly held Prospect Medical to its burden of proof and examined the record to determine that Prospect Medical failed to meet that burden. Although PLIGA did not refer the precertification request to a medical doctor, Prospect Medical’s claims were properly subjected to a medical necessity analysis, consistent with the Legislature’s “intent to discourage the performance of unnecessary medical services.”

“Dismissed”

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Legal Update (February 2026): Since this 2011 decision, New Jersey’s no-fault regulations, medical necessity standards, and arbitration procedures may have been subject to amendments or updates. Practitioners should verify current provisions regarding MUA coverage standards, arbitration forum procedures, and medical necessity documentation requirements under New Jersey’s Personal Injury Protection statutes.