Key Takeaway
New York courts require competent expert medical proof to challenge medical necessity in no-fault insurance disputes, with fair and reasonable charges being key factors.
This article is part of our ongoing fee schedule coverage, with 282 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
New York’s no-fault insurance system creates a complex framework where medical providers and insurers frequently clash over payment obligations. One critical battleground involves disputes over medical necessity—whether specific treatments or services were actually required for a patient’s condition. Understanding when and how these challenges can be raised is essential for both healthcare providers seeking payment and insurers defending against claims.
The burden of proof in medical necessity disputes can be particularly challenging, especially when dealing with out-of-network providers or services rendered outside New York State. Courts have established clear standards for what constitutes adequate evidence to support or refute claims of medical necessity, and these standards can significantly impact the outcome of payment disputes.
Jason Tenenbaum’s Analysis:
Hercules Med., PC v Cabello, 2013 NY Slip Op 52186(U)(App. Term 1st Dept. 2013)
“A fair interpretation of the evidence supports the trial court’s determination that plaintiff, an out-of-network medical service provider, was entitled to recover for examination and testing services rendered to defendant for which defendant failed to pay, despite timely demand. Indeed, defendant did not dispute that the services billed for were rendered, or the reasonableness of the amounts charged for each particular service. Nor did defendant adduce any competent expert medical proof to support her assertion that the services here in dispute were not medically necessary (see Mount Vernon Hosp. v Brennan, 21 Misc 3d 140, 2008 NY Slip Op 52358 ; see generally Viacom Intl. v Midtown Realty Co., 193 AD2d 45, 55 ).”
If you read the Mount Vernon Hospital case that was cited, the Court required the hospital ” establish[] that the charges for the services rendered were fair and reasonable.”
Fair and reasonable seems to be an important issue in the realm of no-fault as it applies to services rendered out of state. Compare, 11 NYCRR 68.6
Key Takeaway
The Hercules Medical decision reinforces that insurers cannot simply assert medical necessity defenses without substantive proof. When challenging medical necessity, insurers must provide competent expert medical evidence—not just conclusory statements. This standard protects healthcare providers from baseless denials while ensuring that medical necessity reversals are grounded in legitimate medical opinions rather than administrative convenience.
The case also highlights the importance of “fair and reasonable” charges, particularly for out-of-state services where New York’s standard fee schedule may not directly apply. This creates additional complexity in New York No-Fault Insurance Law cases involving cross-border medical care, where providers must establish both medical necessity and reasonable pricing to secure payment.
Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance regulations have undergone significant revisions, including amendments to medical necessity determination procedures, updated fee schedules, and revised timeframes for disputing claims. The procedural requirements for challenging medical necessity and the standards for out-of-network provider reimbursements may have been modified through regulatory updates and court decisions. Practitioners should verify current provisions under 11 NYCRR Part 65 and subsequent amendments to ensure compliance with current medical necessity dispute procedures.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
282 published articles in Fee Schedule
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Jul 21, 2015Common Questions
Frequently Asked Questions
What is the no-fault fee schedule?
New York's no-fault fee schedule, established by the Workers' Compensation Board and the Department of Financial Services, sets the maximum reimbursement rates that no-fault insurers must pay for medical services. When an insurer pays less than the billed amount, citing the fee schedule as a defense, the provider can challenge the reduction by demonstrating that the fee schedule was improperly applied or that the services are not subject to fee schedule limitations.
Can a medical provider charge more than the fee schedule allows?
Medical providers treating no-fault patients are generally limited to the amounts set by the fee schedule and cannot balance-bill the patient for the difference. However, certain services may not be covered by the fee schedule, and disputes about whether a specific service falls within the fee schedule are common in no-fault litigation. The Department of Financial Services periodically updates the fee schedule rates.
How are fee schedule disputes resolved in no-fault arbitration?
When an insurer partially pays a claim citing the fee schedule, the provider can challenge the reduction through no-fault arbitration. The provider must demonstrate that the service billed is not subject to the fee schedule or that the fee schedule was incorrectly applied. The insurer bears the burden of proving the fee schedule applies and the correct rate was used. Fee schedule disputes often involve coding issues, modifier usage, and applicability of Workers' Compensation rates.
Does the no-fault fee schedule apply to all medical services?
Not all medical services are subject to the no-fault fee schedule. Certain services, supplies, and procedures may fall outside its scope, in which case the provider may bill the usual and customary rate. Disputes about whether a specific service or billing code is covered by the fee schedule are common. The Workers' Compensation Board fee schedule and the Department of Financial Services ground rules guide which services are covered and at what rates.
What is a medical necessity denial in no-fault insurance?
A medical necessity denial occurs when the insurer's peer reviewer determines that treatment was not medically necessary based on a review of the patient's medical records. The peer reviewer writes a report explaining why the treatment does not meet the standard of medical necessity. To challenge this denial, the provider or claimant must present medical evidence — typically an affirmation from the treating physician — explaining why the treatment was necessary and rebutting the peer review findings.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a fee schedule matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
