All Borough Group Med. Supply, Inc. v Unitrin Advantage Ins. Co., 2014 NY Slip Op 50462(U)(App. Term 2d Dept. 2014)
“At a trial on the issue of medical necessity, although peer review reports are not admissible to prove the lack of medical necessity, in the case at bar, defendant properly established the lack of medical necessity at trial through the testimony of its expert witness based on his independent review of plaintiff’s assignor’s medical records.”
So an independent review of the medical records that is consistent with the medical rationale in the peer review will win the day for the carrier. This holds true for a sub-peer review. Perhaps, I can convince a Kings County Civil Court judge that this is the law…
One Response
This used to drive me nuts. The decision is absurd. The insurer has 30 days from receipt of the bill to pay or properly deny. Proper denial based on lack of medical necessity is done through an ME or peer review that contains a factual basis and medical rationale for the denial. If the defense cannot offer such a peer review at trial, they should lose. Period.
Nothing said by the defense witness, be it the doctor that authored the peer review, or a so-called “re-peer” doctor, should be given any weight or relevance if its not in the explicitly in the peer review itself. To allow otherwise completely abrogates the 30 day rule. Under this ruling, the insurer is no longer required to deny with a factual basis and medical rationale within 30 days as long as they can get someone to show up and give one at trial.