Medical necessity – rebutting a peer review

No-fault insurance disputes often center on whether medical treatment was truly necessary. When insurance companies deny claims based on peer review reports, healthcare providers aren’t left without recourse. The key lies in understanding how to effectively challenge these denials through proper medical documentation and expert testimony.

Under New York No-Fault Insurance Law, insurance carriers frequently use peer review reports to justify claim denials. These reports, prepared by physicians who haven’t examined the patient, can seem difficult to overcome. However, as demonstrated in recent appellate decisions, treating physicians who have direct patient contact often hold significant advantages in these disputes.

Jason Tenenbaum’s Analysis:

Westcan Chiropractic, P.C. v Hertz Claim Mgt., 2015 NY Slip Op 51066(U)(App. Term 2d Dept. 2014)

“In support of its motion, defendant submitted a sworn peer review report which set forth a factual basis and medical rationale for the reviewer’s determination that there was a lack of medical necessity for the services at issue (see American Chiropractic Care, P.C. v Praetorian Ins. Co., 42 Misc 3d 145, 2014 NY Slip Op 50346 ). However, in opposition to the motion, plaintiff submitted an affidavit by one of the assignor’s treating doctors, which, as plaintiff argues on appeal, “meaningfully referred to defendant’s peer review report and sufficiently rebutted the conclusions set forth therein""

Key Takeaway

This case demonstrates that peer review reports, while powerful tools for insurance companies, can be successfully challenged. Healthcare providers must ensure their treating physicians submit detailed affidavits that specifically address and rebut the peer reviewer’s conclusions, rather than simply restating treatment necessity in general terms.

Related Articles

• Understanding IME No-Shows in New York No-Fault Insurance: Rights, Consequences, and Strategic Considerations
• Understanding CPLR 3212(a): Critical Timing Rules for Summary Judgment Motions in New York
• The CPLR 3212(g) paradigm
• No-Fault Verification Requirements: When Partial Compliance Isn’t Enough
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2015 post, New York’s no-fault insurance regulations under Section 5106 have undergone several amendments, particularly regarding peer review procedures, medical necessity standards, and documentation requirements for rebutting denials. Practitioners should verify current provisions of the Insurance Regulations and recent appellate decisions, as both substantive standards and procedural requirements for challenging peer review determinations may have evolved significantly.