Comp defense succeeds but medical necessity defense falters

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.

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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.