9th and 10th are telling the Nassau County District Court (again) that enough is enough

In the complex world of New York no-fault insurance law, medical necessity determinations continue to be a battleground between insurance carriers and healthcare providers. Recent decisions from the 9th and 10th Judicial Districts are sending a clear message to Nassau County District Court and practitioners throughout Long Island and New York City: when it comes to unopposed motions for summary judgment on medical necessity, the rules apply equally to all courts, and proper medical evidence is not optional.

Understanding Medical Necessity in New York No-Fault Cases

Medical necessity disputes form the backbone of no-fault insurance litigation throughout New York State, affecting healthcare providers from Manhattan to Montauk and impacting patients seeking treatment after motor vehicle accidents in Queens, Brooklyn, Nassau County, Suffolk County, the Bronx, and Staten Island. These cases determine whether insurance carriers must pay for medical treatments, diagnostic tests, and therapeutic services provided to injured motorists.

Total Equip., LLC v Praetorian Ins. Co., 2012 NY Slip Op 50078(U)(App. Term 2d Dept. 2012 )

The 9th and 10th again tell Nassau District Court that they are not exempt from the rule that an unopposed lack of medical necessity motion spells doom.

Elmont Open MRI & Diagnostic Radiology, P.C. v Tri State Consumer Ins. Co., 2012 NY Slip Op 50079(U)(App. Term 2d Dept. 2012 )

I like this line:

“Since plaintiff, in opposition to defendant’s motion, failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity, defendant was entitled to summary judgment”

The Persistent Problem: Nassau County District Court’s Resistance

The repeated need for the 9th and 10th Judicial Districts to correct Nassau County District Court decisions reveals a troubling pattern that affects medical providers and patients throughout Nassau County. This judicial district, which serves communities from Garden City to Glen Cove, from Hempstead to Huntington, has shown a reluctance to apply established legal principles consistently in no-fault medical necessity cases.

Why This Pattern Matters for Long Island Healthcare Providers

Healthcare providers throughout Nassau and Suffolk counties who treat motor vehicle accident victims depend on predictable application of legal standards. When lower courts fail to properly apply summary judgment rules in medical necessity cases, it creates:

• Increased litigation costs for medical providers who must appeal improper decisions
• Delayed payments for legitimate medical services
• Uncertainty in treatment decisions for healthcare providers
• Additional burden on appellate courts to correct preventable errors

The Legal Standard: What Courts Must Follow

The appellate decisions in both Total Equipment and Elmont Open MRI reinforce fundamental principles of New York civil procedure that apply throughout the state, from the five boroughs of New York City to Suffolk County’s eastern reaches:

Summary Judgment Standard: When a defendant insurance carrier moves for summary judgment based on lack of medical necessity, they must submit competent medical evidence supporting their position. If the plaintiff healthcare provider fails to oppose this motion with adequate medical evidence, summary judgment must be granted.

Burden of Proof: Once the defendant establishes a prima facie case for lack of medical necessity, the burden shifts to the plaintiff to raise a triable issue of fact through competent medical evidence – not attorney affirmations or unsupported assertions.

Analyzing the Total Equipment Decision

The Total Equipment case represents a clear example of how the legal system should function when medical necessity is properly challenged. The decision sends an important message to courts throughout Nassau County and beyond about the importance of following established procedural rules.

Key Takeaways for Medical Providers

Medical providers throughout Long Island and NYC must understand that when facing a medical necessity challenge:

• Opposing affidavits must be based on medical evidence, not legal argument
• Generic denials or conclusory statements are insufficient
• Competent medical evidence means peer review reports, medical records, and expert medical opinion
• Attorney affirmations alone cannot create a triable issue of fact

The Elmont Open MRI Decision: A Clear Roadmap

The court’s statement in Elmont Open MRI provides a concise but powerful reminder of what constitutes adequate opposition to a medical necessity motion. This principle affects diagnostic imaging centers, physical therapy practices, chiropractic offices, and medical clinics throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island.

What Constitutes “Medical Evidence Sufficient to Raise a Triable Issue”

The Elmont Open MRI decision clarifies that plaintiffs must submit substantial medical evidence, which may include:

• Peer review reports supporting the medical necessity of the disputed treatment
• Medical records documenting the patient’s condition and need for treatment
• Expert medical affidavits explaining why the treatment was medically necessary
• Treatment protocols and clinical guidelines supporting the medical decision
• Follow-up records showing the effectiveness of the treatment

What Does NOT Constitute Sufficient Medical Evidence

The decisions make clear that certain types of submissions are inadequate to oppose medical necessity motions:

• Attorney affirmations without supporting medical documentation
• Conclusory statements about medical necessity
• Generic form letters or template responses
• Unsupported assertions about standard medical practice
• Arguments based solely on legal precedent without medical support

Implications for Different Healthcare Sectors

These decisions have far-reaching implications for various healthcare providers throughout New York’s metropolitan area and Long Island:

Diagnostic Imaging Centers

MRI facilities, CT scan centers, and X-ray providers from Queens to Suffolk County must be prepared to defend the medical necessity of their services with concrete medical evidence. The Elmont Open MRI case specifically demonstrates the standards applied to imaging services.

Physical Therapy and Rehabilitation

Physical therapy practices throughout Nassau and Suffolk counties must maintain detailed treatment records and be prepared to provide medical evidence supporting the necessity of extended therapy programs.

Chiropractic Care

Chiropractors treating motor vehicle accident victims throughout Long Island and New York City must document not only their treatment but also maintain evidence supporting the medical necessity of their care plans.

Medical Supply Companies

Durable medical equipment providers and supply companies like Total Equipment must ensure they have proper medical documentation supporting the necessity of equipment and supplies provided to accident victims.

The Broader Context: New York’s No-Fault System

These decisions reflect ongoing tensions within New York’s no-fault insurance system, which was designed to provide prompt payment for necessary medical care while preventing fraud and unnecessary treatments. The system affects millions of motorists and healthcare providers throughout New York State.

Balancing Access to Care with Cost Control

The appellate courts’ insistence on proper medical evidence serves multiple purposes:

• Protecting insurance carriers from paying for unnecessary treatments
• Ensuring that legitimate medical care receives appropriate payment
• Maintaining the integrity of the no-fault system
• Providing clear standards for healthcare providers to follow

Impact on Insurance Premiums and Healthcare Costs

Proper application of medical necessity standards affects insurance premiums for all New York motorists. When courts fail to apply these standards consistently, it can lead to increased costs throughout the system.

Best Practices for Healthcare Providers

Based on these appellate decisions, healthcare providers throughout Nassau County, Suffolk County, and New York City should implement the following practices:

Documentation Standards

• Maintain detailed medical records supporting all treatment decisions
• Document the medical necessity for each service provided
• Keep copies of all peer review challenges and responses
• Ensure treatment protocols are clearly documented and justified

Litigation Preparation

• Engage qualified medical experts early in disputed cases
• Prepare comprehensive medical evidence packages for contested treatments
• Review and update standard opposition procedures
• Train staff on proper evidence collection and preservation

Frequently Asked Questions About Medical Necessity Motions

What happens if I don’t oppose a medical necessity motion?

If you fail to oppose a motion for summary judgment based on lack of medical necessity, the court will likely grant the motion, resulting in dismissal of your case and denial of payment for the disputed services.

Can an attorney’s affirmation alone defeat a medical necessity motion?

No. As these cases clearly demonstrate, attorney affirmations without supporting medical evidence are insufficient to create a triable issue of fact on medical necessity.

What type of medical evidence is most effective in opposing these motions?

Peer review reports from qualified medical professionals, detailed medical records, and expert medical affidavits that specifically address the medical necessity of the disputed treatment are most effective.

How do these decisions affect pending cases?

These decisions establish binding precedent for the 9th and 10th Judicial Districts and provide persuasive authority for courts throughout New York State.

Should I be concerned if my case is in Nassau County District Court?

While these decisions suggest Nassau County District Court has had difficulty applying proper standards, the appellate oversight should help ensure more consistent application of the law.

The Role of Legal Counsel in Medical Necessity Cases

The complexity of medical necessity litigation requires experienced legal counsel who understand both the medical and legal aspects of these cases. Healthcare providers throughout Long Island and New York City benefit from attorneys who:

• Understand the specific requirements for medical evidence
• Can effectively work with medical experts
• Know the local court practices and preferences
• Stay current with evolving appellate decisions

When to Seek Legal Help

Healthcare providers should consider seeking experienced legal counsel when:

• Facing their first medical necessity challenge
• Dealing with particularly complex medical issues
• Experiencing repeated challenges from the same insurance carrier
• Needing to develop comprehensive opposition strategies

Future Implications and Trends

The continued need for appellate oversight of medical necessity decisions suggests several important trends affecting healthcare providers throughout New York:

Increased Scrutiny of Medical Evidence

Courts are becoming more sophisticated in evaluating medical evidence, requiring healthcare providers to present more comprehensive and detailed support for their treatment decisions.

Standardization of Procedures

Repeated appellate corrections are likely to lead to more standardized procedures and training for lower court judges handling no-fault cases.

Enhanced Documentation Requirements

Healthcare providers should expect increasing demands for detailed documentation supporting medical necessity determinations.

Protecting Your Practice and Your Patients

The decisions in Total Equipment and Elmont Open MRI underscore the critical importance of proper legal representation in medical necessity disputes. Whether you’re a diagnostic imaging center in Nassau County, a rehabilitation facility in Suffolk County, or a medical practice in Queens, understanding and preparing for medical necessity challenges is essential to protecting both your practice’s financial health and your patients’ access to necessary care.

Don’t let inadequate legal preparation result in the loss of legitimate claims. The appellate courts have made the standards clear – now it’s up to healthcare providers and their legal counsel to meet those standards consistently and effectively.

If you’re facing medical necessity challenges or need help preparing for no-fault litigation, contact our experienced legal team at (516) 750-0595. We understand the complex interplay between medical evidence and legal requirements in no-fault cases, and we’re here to help protect your practice and ensure you receive payment for necessary medical services.

Our Long Island and New York City healthcare law attorneys have extensive experience in medical necessity litigation and stay current with the latest appellate decisions affecting your practice. Call (516) 750-0595 today to discuss your case and develop a comprehensive strategy for protecting your interests in the ever-evolving landscape of New York no-fault law.

Related Articles

• Why conclusory affidavits fail in medical necessity summary judgment motions
• Understanding medical necessity requirements for prima facie cases
• When civil court reasoning goes wrong in no-fault insurance cases
• How IME doctors must explain their findings on restricted motion
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2012 analysis, the standards for medical necessity determinations and summary judgment motions in no-fault cases may have evolved through subsequent appellate decisions, regulatory amendments to the Insurance Law, or updates to the no-fault fee schedules and billing procedures. Practitioners should verify current provisions regarding medical necessity documentation requirements and summary judgment standards applicable to unopposed motions.