Key Takeaway
New York court rules that detailed medical affidavit explaining need for MRI to rule out disc herniations creates triable issue of medical necessity in no-fault case.
Medical necessity disputes are at the heart of many no-fault insurance battles in New York. Insurance companies frequently deny claims for diagnostic tests like MRIs, arguing they weren’t medically necessary. Healthcare providers must then prove otherwise through detailed medical documentation and expert opinions.
The Appellate Term’s decision in AP Diagnostic Med., PC v Chubb Indemnity Insurance Co. demonstrates how courts evaluate the sufficiency of medical evidence when providers seek to establish necessity. This case provides important guidance on what level of medical detail is required to survive summary judgment motions in medical necessity disputes.
The court’s approach suggests a trend toward requiring more objective medical foundations in rebuttal affidavits, particularly when challenging diagnostic testing denials. This development has significant implications for both healthcare providers and insurers navigating New York No-Fault Insurance Law.
Jason Tenenbaum’s Analysis:
AP Diagnostic Med., PC v Chubb Indem. Ins. Co., 2013 NY Slip Op 51647(U)(App. Term 1st Dept. 2013)
“The medical affidavit submitted by plaintiff – which detailed the assignor’s complaints of pain and the restricted range of motion of his cervical spine, and opined that the MRI was necessary to rule out disc herniations in the cervical spine – was sufficient to raise a triable issue as to medical necessity (see generally Lee v McQueens, 60 AD3d 914 ; cf. CPT Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co., 18 Misc 3d 87 ).”
This is the second time this Court has cited to a personal injury case to find that medical necessity or lack thereof of diagnostic testing. Diagnostic Medicine, P.C. v Clarendon Natl. Ins. Co., 34 Misc.3d 143(A)(App. Term 1st Dept. 2012). All I can think is that this Court on some level is requiring an objective basis to be found in rebuttal affidavits to defeat medical necessity motions.
Key Takeaway
Healthcare providers can successfully challenge medical necessity denials by submitting detailed medical affidavits that explain specific clinical findings and the diagnostic rationale. Courts increasingly require objective medical foundations rather than conclusory statements when evaluating medical necessity reversals and protection of MRI facilities in no-fault disputes.
Legal Update (February 2026): Since this 2013 decision, New York’s no-fault regulations have undergone several amendments, including updates to medical necessity standards and expert affidavit requirements under 11 NYCRR 65. Additionally, fee schedules and procedural rules governing diagnostic testing disputes may have been modified. Practitioners should verify current regulatory provisions and recent appellate decisions when evaluating medical necessity standards for diagnostic procedures.
