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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.
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.
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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.
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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.
