Key Takeaway
Court ruling clarifies that peer review testimony with independent medical record analysis can establish lack of medical necessity in no-fault insurance disputes.
Understanding how insurance carriers defend against medical necessity claims is crucial for both healthcare providers and patients navigating New York’s no-fault insurance system. While peer review reports alone cannot prove lack of medical necessity at trial, carriers have found success using a more strategic approach that combines expert testimony with independent medical record analysis.
This distinction becomes particularly important when cases proceed to trial rather than being resolved through summary judgment motions. The Appellate Term’s decision in All Borough Group Medical Supply provides valuable guidance on how carriers can effectively challenge medical necessity determinations, especially in cases involving medical necessity reversals.
Jason Tenenbaum’s Analysis:
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…
Key Takeaway
While peer review reports cannot standalone prove lack of medical necessity at trial, insurance carriers can successfully defend claims by presenting expert witness testimony based on independent medical record review that aligns with the peer review’s medical rationale. This strategic approach provides carriers with a pathway to challenge medical necessity even when peer review documentation has evidentiary limitations.
Legal Update (February 2026): Since this 2014 post, New York’s no-fault regulations and medical necessity determination procedures may have been modified through regulatory amendments or court decisions. The admissibility standards for peer review testimony and expert witness requirements in medical necessity disputes may have evolved, and practitioners should verify current evidentiary rules and procedural requirements under the most recent Insurance Law provisions and court precedents.
