Key Takeaway
Court rules on physical therapy medical necessity denial based on chiropractor and physician IME reports, raising questions about cross-disciplinary treatment evaluations.
In New York’s no-fault insurance system, determining medical necessity for ongoing treatment often hinges on independent medical examinations (IMEs) and the quality of medical opposition submitted by healthcare providers. The Glenn Segal PT, P.C. v GEICO case presents an intriguing scenario where both a chiropractor and physician conducted IMEs before physical therapy services were rendered, yet the court’s analysis raises questions about which professional’s opinion carried more weight in the coverage determination.
This case highlights the complex interplay between different medical disciplines in no-fault insurance disputes and demonstrates how inadequate medical opposition can doom a provider’s claim. Understanding these dynamics is crucial for healthcare providers seeking reimbursement and insurers defending medical necessity reversals.
Jason Tenenbaum’s Analysis:
Glenn Segal PT, P.C. v GEICO, 2014 NY Slip Op 51301(U)(App. Term 2d Dept. 2014)
“In support of its cross motion, defendant submitted a sworn statement by the chiropractor who had performed an independent medical examination (IME) of plaintiff’s assignor, as well as an affirmed report by the doctor who had performed a second IME. Both of the IMEs were performed before the services at issue were rendered. Each IME report set forth a factual basis and medical rationale for the examiner’s conclusion that there was a lack of medical necessity for further treatment. In opposition to the cross motion, plaintiff submitted an affidavit from a doctor which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the chiropractor’s report, and further failed to sufficiently rebut the conclusions set forth in the doctor’s report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 )”
Was the cut-off based upon the chiro or the physician? Has to be the latter you would think since it is PT services? Yet, the court commented on the chiro IME. Interesting.
Key Takeaway
This case demonstrates that healthcare providers must adequately address all IME findings in their medical opposition, regardless of the examining professional’s discipline. The failure to meaningfully rebut both the chiropractor’s and physician’s conclusions proved fatal to the physical therapy provider’s claim, even though one might expect only the physician’s opinion to matter for PT services.
Legal Update (February 2026): Since this 2014 post, New York’s no-fault regulations have undergone several amendments affecting IME procedures, medical necessity standards, and provider qualification requirements. Practitioners should verify current provisions regarding IME scheduling requirements, acceptable medical disciplines for examinations, and updated medical opposition standards under the current Insurance Law and Department of Financial Services regulations.
