It involved a different matter.

In no-fault insurance litigation involving medical necessity disputes, healthcare providers must present competent rebuttal evidence that specifically addresses the grounds articulated in insurance company peer review reports. Generic letters of medical necessity and testimony from unrelated cases will not suffice to create triable issues of fact when insurance companies have substantiated their denial based on peer review findings.

This principle reflects a fundamental requirement of New York summary judgment practice: opposition evidence must directly engage with and refute the movant’s specific factual assertions. In the medical necessity context, this means providers cannot defeat insurance company motions through boilerplate statements or evidence that fails to meaningfully address the particular peer review conclusions underlying claim denials.

Understanding what constitutes adequate rebuttal evidence is essential for healthcare providers seeking to overcome medical necessity defenses and for insurance companies establishing their prima facie entitlement to judgment.

Case Background

All Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co., 2013 NY Slip Op 50252(U)(App. Term 2d Dept. 2013)

Prior trial testimony was plainly insufficient to rebut the peer review. Also, a letter of medical necessity was found not to be sufficient to rebut defendant’s prima facie showing. Compare: Quality Psychological, P.C. v. Mercury.

“On appeal, plaintiff argues, among other things, that it raised a triable issue of fact as to the medical necessity of the psychological testing at issue by submitting a letter of medical necessity and the prior trial testimony of a Dr. Franklin Porter. However, the letter of medical necessity did not meaningfully refer to, let alone rebut, the conclusions of defendant’s psychologist (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 ; see also Eastern Star Acupuncture, P.C. v Mercury Ins. Co., 26 Misc 3d 142, 2010 NY Slip Op 50380 ), and Dr. Porter’s testimony has no relevance to the peer review report at issue in this case. While Dr. Porter testified generally, in an unrelated trial, that certain psychological tests have utility, the peer review report relied upon by defendant in this case concluded that they were not medically necessary under the factual circumstances presented by this case. Plaintiff’s remaining contentions on appeal are without merit and/or unpreserved for appellate review.

Legal Significance

The All Boro Psychological Services decision establishes critical requirements for rebuttal evidence in medical necessity disputes. The court’s analysis demonstrates that two common forms of opposition evidence prove insufficient: generic letters of medical necessity that fail to address specific peer review findings, and general expert testimony from unrelated cases that does not engage with the particular factual circumstances at issue.

The requirement that opposition evidence “meaningfully refer to” and “rebut” peer review conclusions imposes a substantive burden on healthcare providers. It is not enough to submit evidence supporting the general proposition that certain treatments or tests have medical value. Rather, providers must present evidence specifically addressing why the peer reviewer’s conclusions were incorrect under the specific facts of the case. This requirement prevents providers from defeating summary judgment through generic or tangential evidence that sidesteps the actual grounds for denial.

The court’s rejection of prior trial testimony from an unrelated case reinforces that medical necessity determinations are fact-specific. Even when an expert has previously testified that certain psychological tests have utility, that testimony cannot create a triable issue of fact in a different case involving different patients and different clinical circumstances. Each peer review report must be addressed based on its specific factual findings and conclusions.

This decision reflects a broader principle in summary judgment practice: opposition evidence must be responsive to the movant’s showing. Courts will not credit evidence that talks past the issues actually raised by the moving party or that addresses different questions than those presented by the motion.

Practical Implications

For healthcare providers defending against medical necessity challenges, this decision requires careful attention to the specific grounds articulated in peer review reports. Providers must obtain complete copies of peer review reports through discovery and craft opposition evidence that directly engages with the reviewer’s findings. Form letters of medical necessity or generic expert affidavits will not suffice.

When providers seek expert affidavits to rebut peer review reports, those affidavits must reference the specific peer review report, address its particular findings, and explain why the conclusions reached were medically incorrect. The expert should review the actual medical records involved in the case and provide opinions grounded in the specific clinical presentation and treatment history of the patient at issue.

For insurance companies, this decision provides strong support for medical necessity defenses based on peer review reports. Once an insurer establishes a prima facie case through a peer review report concluding that services were not medically necessary, the burden shifts to the provider to submit responsive evidence. Companies can successfully argue that generic letters and unrelated testimony fail to meet this burden, securing dismissal of claims without trial.

The decision also highlights the importance of comprehensive peer review reports that clearly articulate specific grounds for finding lack of medical necessity. Well-drafted peer review reports that identify particular factual circumstances and explain why treatments were not warranted under those circumstances create a higher bar for provider rebuttal and increase the likelihood of prevailing on summary judgment.

Related Articles

• Why conclusory affidavits fail in medical necessity summary judgment motions
• How Geico’s medical necessity motions were denied based on boilerplate letters
• Effective strategies for rebutting peer reviews in no-fault insurance cases
• Why poorly drafted medical affidavits fail against insurance company motions
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2013 decision, New York’s no-fault regulations governing peer review procedures and medical necessity determinations may have been amended, including potential changes to the standards for rebutting peer review reports and the evidentiary requirements for letters of medical necessity. Practitioners should verify current regulatory provisions under 11 NYCRR Part 65 and recent case law developments regarding the sufficiency of medical opposition evidence.