Total Equip., LLC v Mercury Cas. Co., 2013 NY Slip Op 52220(U)(App. Term 2d Dept 2013)
“In support of its motion for summary judgment, defendant submitted, among other things, an affirmed independent medical examination (IME) report, in which the doctor concluded, based on her December 3, 2009 independent orthopedic evaluation of the assignor, that the assignor’s injuries had resolved and that there was no need for durable medical equipment, testing or treatment. The report set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the supplies at issue.”
“Based upon the IME report, defendant denied reimbursement of no-fault benefits as of December 18, 2009. While plaintiff argues that the prescription for the supplies was written prior to the IME, it is undisputed that the prescription was not filled until December 21, 2009, subsequent to the effective date of the denial. Consequently, the burden shifted to plaintiff to rebut defendant’s prima facie showing that there was a lack of medical necessity for the supplies at issue.”
So the medical necessity for post IME services is measured from when the service is acquired or used, not when it is prescribed. This rule makes sense.
