Key Takeaway
Two 2014 New York appellate decisions demonstrate how insurance companies can successfully challenge medical necessity claims when healthcare providers fail to properly rebut peer review reports.
Medical necessity disputes represent one of the most contentious battlegrounds in New York No-Fault Insurance Law. When insurance companies deny claims for medical equipment or treatment based on lack of medical necessity, healthcare providers must present compelling evidence to overcome these determinations. Two 2014 appellate decisions from Kings County illustrate how inadequate responses to peer review reports can doom otherwise valid claims.
These cases highlight the critical importance of understanding what constitutes sufficient medical opposition when challenging insurance company denials. As we’ve previously discussed regarding peer review requirements, the standard for overcoming medical necessity challenges has specific procedural requirements that providers ignore at their peril.
Jason Tenenbaum’s Analysis:
Promed Durable Equip., Inc. v GEICO Ins., 2014 NY Slip Op 51262(U)(App. Term 2d Dept. 2014)
Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.)
“Defendant also an nexed to its motion papers two affirmed peer review reports, each of which set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the supplies at issue. Plaintiff did not rebut defendant’s prima facie showing. Accordingly, the order is reversed and defendant’s cross motion for summary judgment dismissing the complaint is granted”
Quality Health Prods., Inc. v Geico Ins. Co., 2014 NY Slip Op 51268(U)(App. Term 2d Dept. 2014)
Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.)
“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 peer review reports (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 ).”
** I am sure the number would be higher if everybody appealed this judge’s orders.
Key Takeaway
Healthcare providers must do more than simply submit a doctor’s affidavit when challenging medical necessity denials. The opposition must specifically address and meaningfully rebut the conclusions in the insurance company’s peer review reports. Generic medical opinions that fail to engage with the specific findings will not survive summary judgment motions.
Legal Update (February 2026): Since this 2014 post, New York’s no-fault regulations governing medical necessity determinations and peer review procedures may have been subject to amendments, including potential updates to evidence standards, peer review timeframes, and procedural requirements for challenging insurance denials. Practitioners should verify current regulatory provisions under 11 NYCRR Part 65 and recent appellate decisions when handling medical necessity disputes.
