Key Takeaway
Court rules subjective patient complaints without objective medical evidence insufficient to deny acupuncture treatment necessity in no-fault insurance case.
Objective Evidence Requirements in No-Fault Medical Necessity Determinations
In no-fault insurance disputes, insurance companies frequently challenge the medical necessity of ongoing treatment through independent medical examinations (IMEs) and peer reviews. However, courts consistently require that these challenges be supported by objective medical evidence rather than subjective patient statements alone. The recent Easy Care Acupuncture decision demonstrates how insurance companies cannot rely solely on a patient’s subjective complaints during a peer review to deny coverage for continued treatment.
This case highlights critical procedural requirements for no-fault insurance carriers seeking to terminate benefits. When peer reviewers make determinations outside their area of expertise or fail to provide objective medical reasoning, courts will not grant summary judgment to deny coverage. The decision also reinforces established precedent regarding medical necessity reversals when insurance companies fail to meet their evidentiary burden.
Jason Tenenbaum’s Analysis:
Easy Care Acupuncture, P.C. v A. Cent. Ins. Co., 2015 NY Slip Op 50973(U)(App. Term 1st Dept 2015)
That the assignor may have subjectively reported during the course of the peer review examination that he “feels worse” after two months of treatment did not, by itself and without any objective medical explanation by the peer reviewer, eliminate all triable issues regarding the medical necessity of continued acupuncture treatment, especially in view of the peer reviewer’s own positive findings (see Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co., 46 Misc 3d 126, 2014 NY Slip Op 51766). In addition, the peer reviewer’s statement that “with respect to the right shoulder complaints, further comment outside my area of expertise is deferred to the appropriate specialist,” was hardly sufficient to permit a summary determination as to the medical necessity of continued treatment related to this injury.”
Again, an objective standpoint is used to discuss the gambit of the propriety of an IME review. Also, the “outside my expertise” argument furthermore spells disaster.
Key Takeaway
Insurance companies cannot deny medical necessity based solely on subjective patient complaints during peer reviews. Courts require objective medical evidence and qualified expert opinions within the reviewer’s area of expertise. When peer reviewers acknowledge limitations in their expertise or fail to provide objective medical reasoning, summary judgment motions for benefit termination will be denied.
