Comp defense succeeds but medical necessity defense falters

Divergent Evidentiary Standards for Fee Schedule and Medical Necessity Defenses

New York’s no-fault insurance system permits insurers to defend against provider claims through multiple procedural and substantive defenses, each governed by distinct evidentiary requirements. The Martin Plutno decision demonstrates how different defenses demand different types and levels of proof—a mathematical calculation performed by an insurance company employee suffices for fee schedule reduction defenses, while medical necessity challenges require sworn statements from examining physicians containing detailed medical rationale. Understanding these divergent standards is essential for both insurers structuring their defenses and providers crafting responsive opposition.

The case also highlights a critical jurisprudential divide between New York’s appellate departments regarding what evidence suffices to defeat medical necessity summary judgment motions. While the Second Department has adopted a relatively permissive standard allowing sworn letters of medical necessity from treating providers to create triable issues of fact, the First Department applies more stringent requirements examining whether opposition papers demonstrate treatment was medically necessary “here at issue”—not in general, but for this specific patient’s specific condition as documented in contemporaneous medical records. This departmental split creates forum-dependent litigation strategies and unpredictable outcomes for cases that could be venued in multiple jurisdictions.

For practitioners, these divergent standards require tailoring litigation strategies to the anticipated forum. Providers litigating in the Second Department can often defeat medical necessity summary judgment through relatively straightforward letters from treating physicians affirming that treatment was necessary. By contrast, providers facing First Department scrutiny must present detailed medical evidence connecting specific treatments to documented objective findings, quantified limitations, and reasonable treatment progressions. This geographic variation in evidentiary standards creates significant inconsistency in how identical claims might be resolved depending on venue.

The decision also demonstrates how insurance companies can achieve partial victories through strategically combining multiple defenses. Even when one defense fails—as the medical necessity challenge did here—other defenses like fee schedule reductions can succeed, limiting the provider’s ultimate recovery. This layered defense strategy reflects sophisticated claims management where carriers pursue multiple grounds for denial or reduction, recognizing that success on any ground reduces their ultimate liability.

Case Background: Dual Defenses Producing Split Results

Martin Plutno, apparently a medical provider or assignee, sued Travelers Insurance Company seeking reimbursement for services rendered between August 3, 2007 and August 25, 2007, totaling $235.90. Travelers moved for summary judgment asserting two distinct defenses: first, that the provider’s bills exceeded the amounts permitted under the workers’ compensation fee schedule, which serves as the reimbursement ceiling for certain no-fault services; and second, that an independent medical examination established lack of medical necessity for continued treatment.

On the fee schedule defense, Travelers submitted an affidavit from a company employee establishing that the carrier had already paid $134.80 of the $235.90 claimed, and had denied the remaining $101.10 because the billed amount exceeded fee schedule limits. This relatively straightforward mathematical demonstration—showing amounts billed, amounts permitted under the fee schedule, amounts already paid, and amounts properly denied—proved sufficient to establish prima facie entitlement to partial summary judgment.

On the medical necessity defense, Travelers submitted a sworn statement from a chiropractor who performed an independent medical examination (IME) of the claimant. The IME chiropractor’s statement set forth a factual basis for the examination findings and provided medical rationale explaining why, in the examiner’s professional opinion, further treatment lacked medical necessity. This evidence appeared facially sufficient to shift the burden to the plaintiff to raise a triable issue of fact regarding medical necessity.

In opposition, Plutno submitted various papers including a letter of medical necessity sworn to by the treating chiropractor. This opposition letter, though less detailed than might be required in some circumstances, was sufficient under the Second Department’s standards to create a factual dispute precluding summary judgment on the medical necessity issue.

Jason Tenenbaum’s Analysis:

Martin Plutno v Travelers Ins. Co., 2014 NY Slip Op 50412(U)(App. Term 2d Dept. 2014)

(1) Simple fee schedule arithmetic may be performed by “defendant’s employee”: “The affidavit submitted by defendant’s employee established that, as to plaintiff’s claim for dates of service August 3, 2007 through August 25, 2007 seeking the sum of $235.90, defendant had paid $134.80 thereof and had denied the remaining $101.10 on the ground that the amount billed by plaintiff exceeded the fees allowed by the workers’ compensation fee schedule.”

(2) “defendant submitted a sworn statement by the chiropractor who had performed an independent medical examination (IME), which set forth a factual basis and medical rationale for the chiropractor’s conclusion that there was a lack of medical necessity for further treatment”

(3) “However, plaintiff did submit, among other things, a letter of medical necessity sworn to by plaintiff’s treating chiropractor, which was sufficient to raise a triable issue of fact as to the medical necessity of the services rendered”

My own thought process is now there is another split in the departments.  The First Department has a more stringent post-IME “here at issue test”.  This Court solely requires a letter of medical necessity to defeat a summary judgment motion.

Legal Significance: The Minimal Opposition Standard in the Second Department

This decision establishes that within the Second Department’s jurisdiction, medical providers can defeat medical necessity summary judgment motions through relatively minimal opposition—a sworn letter from the treating provider affirming medical necessity. The court did not require detailed explanations of specific objective findings, quantified measurements of functional limitations, descriptions of treatment progression, or citations to accepted medical literature supporting the treatment approach. A simple sworn affirmation that treatment was medically necessary sufficed to create a triable issue of fact.

This permissive standard contrasts sharply with the First Department’s “here at issue” test, which examines whether opposition evidence demonstrates medical necessity for the specific treatments at issue based on contemporaneous medical documentation. Under the stricter First Department approach, conclusory letters asserting general medical necessity without connecting treatment to specific documented findings often fail to raise factual issues. The divergence reflects fundamentally different judicial philosophies about the quantum of evidence required to warrant trial on medical necessity disputes.

The decision also validates the use of insurance company employees to establish fee schedule defenses through mathematical calculations. Courts recognize that determining whether billed amounts exceed fee schedule limits involves arithmetic rather than specialized medical or insurance expertise. Therefore, employees with knowledge of billing records and fee schedule provisions can provide sufficient foundation through affidavits, without requiring testimony from physicians, certified medical coders, or other specialized experts.

Practical Implications: Forum-Specific Litigation Strategies

For medical providers defending against medical necessity challenges, this decision underscores the critical importance of venue. Cases litigated in the Second Department permit providers to defeat summary judgment through relatively simple letters of medical necessity from treating providers. Providers should ensure their treating physicians are willing to provide sworn letters supporting medical necessity and should obtain such letters before responding to summary judgment motions.

Conversely, for insurance companies pursuing medical necessity defenses in the Second Department, this decision signals that summary judgment may prove difficult to obtain even with strong IME evidence. Carriers should recognize that unless the plaintiff completely fails to respond or provides only unsworn statements, courts will likely find triable issues warranting trial. This reality counsels in favor of earlier settlement discussions or alternative litigation strategies.

The departmental split also creates strategic opportunities for providers who can choose between forums. When jurisdiction exists in multiple counties spanning different departments, providers may benefit from filing in the Second Department where the more permissive medical necessity standard increases their likelihood of surviving summary judgment.

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• How boilerplate letters of medical necessity lead to denied motions
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• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2014 decision, New York’s no-fault fee schedules have undergone multiple revisions, and regulatory amendments may have altered reimbursement calculation methodologies and medical necessity documentation requirements. Additionally, appellate decisions in the intervening years may have further clarified or modified the standards for defeating summary judgment motions based on medical necessity challenges. Practitioners should verify current fee schedule provisions and recent case law regarding sufficiency of medical opposition evidence.