Key Takeaway
Court finds MUA procedures lacked medical necessity when services didn't follow established guidelines, showing how peer review can defeat no-fault claims.
Manipulation Under Anesthesia (MUA) cases present unique challenges in New York’s no-fault insurance system. When healthcare providers perform MUA procedures, insurance companies often scrutinize these treatments closely due to their invasive nature and significant cost. The case of Synergy Med. v Praetorian Ins. Co. demonstrates how courts evaluate medical necessity in MUA cases, particularly when the performed services deviate from established professional guidelines.
This decision illustrates the importance of proper documentation and adherence to recognized medical protocols in New York No-Fault Insurance Law cases. When insurance companies can demonstrate through peer review that treatments don’t meet accepted standards, providers face an uphill battle in proving medical necessity.
Jason Tenenbaum’s Analysis:
Synergy Med. v Praetorian Ins. Co., 2013 NY Slip Op 51047(U)(App. Term 1st Dept. 2013)
“Notably, defendant’s peer reviewer explained in some detail that the manipulation under anesthesia (“MUA”) procedures performed at plaintiff’s facility were not medically necessary according to the standards of protocol followed by the National Academy of MUA physicians.”
…
“The unsworn operative reports of plaintiff’s principal submitted with plaintiff’s attorney’s affirmation were without probative value (see Grasso v Angerami, 79 NY2d 813 ). In any event, even if considered, the conclusory, fill-in-the-blanks findings set forth therein were insufficient to withstand summary judgment”
Definitely a plan of attack on MUA cases.
Key Takeaway
This case establishes that when MUA services are inconsistent with recognized professional guidelines, insurance companies can create a prima facie showing of lack of medical necessity. Healthcare providers must ensure their documentation goes beyond conclusory, fill-in-the-blank reports to successfully defend against medical necessity reversals. The court’s emphasis on detailed peer review analysis shows how a copy of a peer report is all that is needed to shift the burden to providers.
Legal Update (February 2026): Since this 2013 decision, New York’s no-fault regulations regarding medical necessity determinations and peer review standards may have been updated through regulatory amendments or Department of Financial Services guidance. Additionally, court precedents regarding the sufficiency of medical evidence and expert testimony requirements in MUA cases may have evolved, so practitioners should verify current procedural requirements and evidentiary standards when handling similar medical necessity disputes.
