Key Takeaway
Court upholds medical necessity defense despite plaintiff's challenges to peer review doctor qualifications in Five Boro Med case.
Medical necessity disputes in New York no-fault insurance cases often hinge on the quality and sufficiency of evidence presented by both sides. When healthcare providers challenge insurance company denials based on medical necessity grounds, the courts scrutinize whether adequate proof has been submitted to create genuine issues of material fact.
The Appellate Term’s decision in Five Boro Medical Equipment demonstrates the critical importance of supporting opposition papers with substantive medical evidence rather than relying solely on attorney arguments. This case also illustrates how challenges to peer review physicians’ qualifications are typically viewed by courts — as matters affecting the weight rather than admissibility of expert testimony.
Jason Tenenbaum’s Analysis:
Five Boro Med. Equip., Inc. v New York Cent. Mut. Fire Ins. Co., 2014 NY Slip Op 51888(U)(App. Term 1st Dept. 2014)
“Plaintiff’s opposing submission, consisting of an attorney’s affirmation unaccompanied by any medical evidence or other competent proof, was insufficient to raise a triable issue (see Munoz v Hollingsworth, 18 AD3d 278, 279 ; CPT Med. Servs., P.C. v NY Cent. Mut. Fire Ins. Co., 18 Misc 3d 87 ). Plaintiff’s objections to the peer review doctor’s qualifications “go to the weight and not the admissibility of her opinion” (Solano v Ronak Med. Care, 114 AD3d 592 ).”
Certain judges often play the qualification card. It works when dealing with nurses and fee schedule coders. It does not work with peer review doctors, unless the service being reviewed is of a sub-specialty that the Geffner rule would apply.
Key Takeaway
Healthcare providers must submit substantive medical evidence, not just attorney arguments, to successfully oppose medical necessity denials. Courts typically reject challenges to peer review physicians’ qualifications as going to weight rather than admissibility, though specialty-specific requirements may apply in certain circumstances. Understanding when disclosure is needed versus when summary judgment is appropriate remains crucial for effective litigation strategy.
Legal Update (February 2026): Since this 2015 post, New York’s no-fault fee schedules and medical necessity review procedures may have been subject to regulatory amendments or updates. The referenced reimbursement standards and peer review protocols discussed in relation to medical necessity determinations should be verified against current Insurance Department regulations, as fee schedules are periodically revised and procedural requirements may have evolved.
