Key Takeaway
Appellate Term Second Department ruling clarifies medical rationale requirements in DME cases, emphasizing need for meaningful opposition to peer review reports.
The landscape of durable medical equipment (DME) disputes in New York’s no-fault insurance system continues to evolve through appellate court decisions. DME cases often present unique challenges for healthcare providers seeking reimbursement, as insurers frequently challenge the medical necessity of prescribed equipment and supplies. The standards for what constitutes sufficient medical rationale in these disputes have been refined through various court rulings, with particular attention paid to how providers must respond to peer review challenges.
Understanding the quality of medical opposition required in DME cases is crucial for practitioners navigating New York No-Fault Insurance Law. The courts have consistently emphasized that healthcare providers cannot simply submit generic medical affirmations when responding to detailed peer review reports that challenge medical necessity determinations.
Jason Tenenbaum’s Analysis:
Park Slope Med. v Praetorian Ins. Co., 2013 NY Slip Op 50761(U)(App. Term 2d Dept. 2013)
Is there something about durable medical equipment that brings out the ire of Appellate Term Justices? Last year, the First Department had something to say about DME. Now a panel of judges, who in my opinion, are not all too friendly to the carriers had this to say:
“Defendant submitted a sworn peer review report which set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the medical supplies at issue, in that the supplies were superfluous, given that the assignor was already receiving three forms of therapy, which the peer reviewer stated was “more than adequate.” In opposition, plaintiff submitted an affirmation by a medical doctor which failed to meaningfully refer to, let alone rebut, the conclusions set forth in the peer review report”
Key Takeaway
This decision reinforces that healthcare providers must submit substantive medical opposition that directly addresses and rebuts specific conclusions in peer review reports. Generic medical affirmations that fail to engage with the insurer’s detailed medical rationale will not suffice to overcome medical necessity challenges, even before panels generally considered favorable to providers.
Legal Update (February 2026): Since this 2013 decision regarding DME medical necessity standards, New York’s no-fault regulations have undergone multiple amendments, including updates to medical necessity guidelines, peer review procedures, and documentation requirements. The fee schedules and reimbursement methodologies for durable medical equipment have also been revised several times. Practitioners should verify current regulatory provisions and recent appellate decisions to ensure compliance with current standards for medical evidence sufficiency in DME disputes.
