Key Takeaway
Court rules peer review report insufficient to deny acupuncture no-fault claims when review only addressed prior time period, not future treatments.
Shirom Acupuncture, P.C. v Kemper Independence Ins. Co., 2014 NY Slip Op 51407(U)(App. Term 1st Dept. 2014)
“We agree that the peer review report relied upon by the defendant-insurer was insufficient to establish, as a matter of law, that the acupuncture services underlying plaintiff’s $2,175 no-fault claim lacked medical necessity. The report addressed the medical necessity of acupuncture services rendered to plaintiff’s assignor during a time frame prior to that covered by the bills sued upon here, with defendant’s peer reviewer basing his finding of a lack of medical necessity on narrow grounds, viz., the perceived vagueness of the provider’s initial acupuncture report and treatment notes. In such form, and since defendant’s peer reviewer stopped short of concluding that the assignor’s medical condition could never be shown to warrant further acupuncture treatments, his report cannot be read so broadly as to justify, without more, the denial of any and all future claims for acupuncture services rendered to the assignor. Thus, summary judgment dismissal of this claim was properly withheld.”
This one is interesting. How many acupuncture cases have you seen where the insurance carrier denied all billing based upon a prior peer review? I am surprised this was taken on appeal. But what is interesting is that a peer review for an initial set of services can state broadly that all further services would not be medically necessary and the peer would (it appears) satisfy the initial burden of persuasion.
This case can definitely be used (with a proper peer review) to substantiate the denial of all pre-IME conservative therapeutic service.
Related Articles
- Why conclusory affidavits fail in opposing medical necessity summary judgment motions
- Understanding medical necessity standards in First Department no-fault insurance cases
- Requirements for IME doctors to explain their medical necessity conclusions
- Establishing a prima facie case of medical necessity in no-fault claims
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2014 decision, New York’s no-fault regulations and peer review procedures may have been subject to amendments, particularly regarding the scope and specificity required for peer review denials of acupuncture and other alternative medical treatments. Practitioners should verify current peer review standards and procedural requirements under the most recent Insurance Department regulations and case law developments.
