Key Takeaway
Court clarifies that IME reports cannot retroactively establish lack of medical necessity for treatments provided before the examination date.
In New York’s no-fault insurance system, insurance companies frequently use Independent Medical Examinations (IMEs) to challenge the medical necessity of treatments provided to accident victims. These examinations are conducted by doctors chosen by the insurance company to evaluate whether ongoing or proposed treatments are medically warranted. However, a fundamental question arises: can an IME conducted on one date be used to deny coverage for treatments that occurred weeks or months earlier?
This timing issue is crucial for both healthcare providers and patients seeking reimbursement under New York No-Fault Insurance Law. When insurance companies deny claims based on lack of medical necessity, they must provide proper documentation to support their position. The timing of when this documentation is obtained relative to when treatments were provided can significantly impact the outcome of coverage disputes.
The Appellate Term’s decision in Dr. Todd Goldman, D.C., P.C. v Kemper Casualty Insurance Company addresses this temporal relationship and establishes important precedent for medical necessity reversals in no-fault cases.
Jason Tenenbaum’s Analysis:
Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co., 2012 NY Slip Op 51296(U)(App. Term 2d Dept. 2012)
“However, as to plaintiff’s claim for $261.60 for services rendered on November 12, 2007, defendant failed to establish a lack of medical necessity for those services, which were rendered before the March 22, 2008 IME.”
Sounds so obvious… an IME is prospective. I think this is the first time I saw a case explicitly say this.
Key Takeaway
This decision establishes that IME reports are prospective evaluations that cannot retroactively determine the medical necessity of treatments already provided. Insurance companies must have contemporaneous documentation to deny coverage for past services. This principle protects healthcare providers from arbitrary claim denials based on examinations conducted months after treatment, ensuring that a copy of a peer report is all that is needed to establish medical necessity challenges must be timely and relevant to the specific treatment dates in question.
Legal Update (February 2026): Since 2012, New York’s no-fault regulations and medical necessity determination procedures may have been modified through regulatory amendments or updated insurance department guidelines. Practitioners should verify current provisions regarding IME timing requirements and medical necessity evaluation standards, as procedural changes or updates to the fee schedule may have affected how temporal relationships between examinations and treatments are assessed in coverage disputes.
