Key Takeaway
New York court clarifies that peer review reports need only be copies when requested by providers, and cannot be used as evidence to prove lack of medical necessity at trial.
In New York’s no-fault insurance system, peer review reports play a crucial role in determining medical necessity for treatments and services. These reports are generated when insurance companies question whether specific medical treatments were necessary for accident-related injuries. However, there’s often confusion about what format these reports must take when provided to healthcare providers, and more importantly, how they can be used in litigation.
A recent Appellate Term decision provides important clarity on both the procedural requirements for peer review reports and their evidentiary limitations. The ruling addresses two key issues: what constitutes adequate disclosure when providers request copies of peer review reports, and whether these reports can be admitted as evidence during trial proceedings involving medical necessity disputes.
Jason Tenenbaum’s Analysis:
A-Quality Med. Supply v GEICO Gen. Ins. Co., 2013 NY Slip Op 23088 (App. Term 2d Dept. 2013)
“The Insurance Department Regulations require merely that a “copy” of a peer review report be produced to a provider upon written demand…. Moreover, the Insurance Department Regulations do not prescribe a format for a peer review report. It is only when a peer review report is being submitted in support of or in opposition to a motion that it must be properly sworn or affirmed (see CPLR 3212 )”
…
“We note that, at trial, the issue of medical necessity is to be resolved based upon the testimony given by medical experts. A peer review report, unlike a witness, is not subject to cross-examination and is not admissible by defendant to prove lack of medical necessity. Indeed, admission of a peer review report into evidence as part of a defendant’s proof of lack of medical necessity may constitute impermissible bolstering of its expert’s testimony”
So, the peer review itself, if admitted into evidence, constitutes improper bolstering. Also, “admissible form” is limited to a motion for summary judgment in opposition to a motion thereto.
Key Takeaway
This decision establishes that insurance companies only need to provide simple copies of peer review reports to healthcare providers upon request - no special format is required. Crucially, these reports cannot be used as evidence at trial to prove lack of medical necessity, as they constitute impermissible bolstering of expert testimony and cannot be cross-examined like live witnesses would be during summary judgment proceedings.
Legal Update (February 2026): Since this 2013 decision, New York’s no-fault regulations have undergone several amendments, particularly regarding peer review procedures and documentation requirements. Practitioners should verify current provisions in 11 NYCRR Part 65 and any subsequent regulatory updates that may have modified the format requirements, disclosure procedures, or evidentiary standards for peer review reports in medical necessity disputes.
