Key Takeaway
Two 2014 New York appellate decisions demonstrate how insurance companies can successfully challenge medical necessity claims when healthcare providers.
This article is part of our ongoing medical necessity coverage, with 171 published articles analyzing medical necessity issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
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.)
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“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.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Medical Necessity Disputes in No-Fault Insurance
Medical necessity is the most common basis for no-fault claim denials in New York. Insurers hire peer reviewers to opine that treatment was not medically necessary, shifting the burden to providers and claimants to demonstrate otherwise. The legal standards for establishing and rebutting medical necessity — including the sufficiency of peer review reports, the qualifications of reviewing physicians, and the evidentiary burdens at arbitration and trial — are the subject of extensive case law. These articles provide detailed analysis of medical necessity litigation strategies and court decisions.
171 published articles in Medical Necessity
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a medical necessity matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
