Key Takeaway
Court ruled peer review report lacked factual basis for denying medical supplies, showing First Department's higher scrutiny standards for peer reviews in no-fault cases.
In New York’s no-fault insurance system, peer review reports play a crucial role when insurers deny claims for medical necessity. These reports must provide detailed medical rationale to justify coverage denials, not just conclusory statements. The First Department Appellate Term has established particularly rigorous standards for what constitutes adequate peer review documentation.
This case demonstrates the importance of thorough peer review analysis in New York no-fault insurance law disputes. When insurers fail to provide sufficiently detailed peer reviews, they cannot meet their burden to eliminate triable issues of fact regarding medical necessity, potentially leading to medical necessity reversals.
Jason Tenenbaum’s Analysis:
Amherst Med. Supply, LLC v A. Cent. Ins. Co., 2013 NY Slip Op 51800(U)(App. Term 1st Dept. 2013)
“The peer review report and accompanying affidavit submitted by defendant’s chiropractor failed to set forth a factual basis or medical rationale for his stated conclusion that the medical supplies here at issue were not medically necessary. The peer reviewer’s bald assertion that “I do not find the need for … durable medical goods,” was insufficient to meet defendant’s prima facie burden of eliminating all triable issues as to medical necessity.”
This Court tends to scrutinize peer reports and rebuttals more than the Second Department. Thus, while this Court will hold the providers to a higher burden to satisfy the Pan Chiro/CPT Medical test, the proof needed to shift the burden is accordingly higher.
Key Takeaway
The First Department requires peer reviewers to provide detailed factual basis and medical rationale for their conclusions. Unlike situations where a copy of a peer report is all that is needed, conclusory statements without supporting analysis will not satisfy the insurer’s burden to eliminate triable issues of medical necessity.
Legal Update (February 2026): Since this 2013 decision, New York’s peer review standards and medical necessity evaluation procedures may have been modified through regulatory amendments, updated Insurance Department guidance, or subsequent appellate decisions. Practitioners should verify current peer review documentation requirements and medical necessity standards under the most recent no-fault regulations and case law.
