Key Takeaway
New Jersey Appellate Division reviews MUA medical necessity standards, examining $18K+ claims and NAMUAP protocols in no-fault insurance dispute
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.
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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- New York No-Fault Insurance Law
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.
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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Jan 27, 2012Common Questions
Frequently Asked Questions
What is a medical necessity denial in no-fault insurance?
A medical necessity denial occurs when the insurer's peer reviewer determines that treatment was not medically necessary based on a review of the patient's medical records. The peer reviewer writes a report explaining why the treatment does not meet the standard of medical necessity. To challenge this denial, the provider or claimant must present medical evidence — typically an affirmation from the treating physician — explaining why the treatment was necessary and rebutting the peer review findings.
How do you challenge a peer review denial?
To overcome a peer review denial, you typically need an affirmation or affidavit from the treating physician that specifically addresses and rebuts the peer reviewer's findings. The treating physician must explain the medical rationale for the treatment, reference the patient's clinical findings, and demonstrate why the peer reviewer's conclusions were incorrect. Generic or conclusory statements are insufficient — the response must be detailed and fact-specific.
What criteria determine medical necessity for no-fault treatment in New York?
Medical necessity is evaluated based on whether the treatment is appropriate for the patient's diagnosed condition, consistent with accepted medical standards, and not primarily for the convenience of the patient or provider. Peer reviewers assess factors including clinical findings, diagnostic test results, treatment plan consistency with the diagnosis, and whether the patient is showing functional improvement. Treatment that is excessive, experimental, or unsupported by objective findings may be deemed not medically necessary.
Can an insurer cut off no-fault benefits based on one IME?
Yes, an insurer can discontinue benefits after a single IME doctor concludes that further treatment is not medically necessary or that the claimant has reached maximum medical improvement. However, the IME report must be sufficiently detailed and the denial must be issued within 30 days under 11 NYCRR §65-3.8(c). The treating physician can submit a rebuttal affirmation explaining why continued treatment is necessary, forming the basis for challenging the cut-off at arbitration.
What is a peer review in no-fault insurance?
A peer review is a paper-based evaluation where a licensed medical professional reviews the patient's records and renders an opinion on whether the billed treatment was medically necessary. Unlike an IME, the peer reviewer does not examine the patient. The peer review report must be detailed, address the specific treatment at issue, and explain the medical rationale for the opinion. Generic or boilerplate peer reviews that fail to address the patient's individual clinical presentation may be found insufficient.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
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.
