On medical necessity

Understanding Medical Necessity in No-Fault Insurance Disputes

Medical necessity determinations form the cornerstone of New York No-Fault Insurance Law disputes. Insurance companies frequently challenge healthcare providers’ claims by arguing that certain treatments were not medically necessary, often relying on independent medical examinations (IMEs) to support their position. However, as demonstrated in recent appellate decisions, the quality of evidence presented and the procedural requirements can significantly impact the outcome of these disputes.

The case of Huntington Regional Chiropractic v Truck Insurance Exchange illustrates the delicate balance courts must strike when evaluating competing medical opinions. While insurers may present seemingly strong IME reports, healthcare providers retain the right to challenge these determinations with their own medical evidence, potentially creating disputes that require trial resolution rather than summary judgment.

The Prima Facie Standard for Medical Necessity Denials

Under Insurance Law § 5102(a), first-party benefits cover “basic economic loss” including “necessary medical and rehabilitative services.” This seemingly straightforward language has generated extensive litigation as insurance carriers and healthcare providers dispute what constitutes “necessary” treatment. The statutory framework grants insurers the right to conduct independent medical examinations under 11 NYCRR § 65-3.5(b), providing a mechanism to challenge treatment necessity through expert medical opinion.

Appellate courts have established that insurance carriers satisfy their prima facie burden on summary judgment by submitting IME reports that contain both a factual basis and medical rationale for concluding treatment was unnecessary. The standard emerged from cases like Total Equip., LLC v Praetorian Ins. Co., which held that conclusory IME reports lacking adequate explanation fail to establish entitlement to summary judgment. The requirement for factual basis and medical rationale ensures that medical necessity determinations rest on substantive clinical analysis rather than unsupported opinion.

The procedural framework requires careful attention to foundational requirements. IME reports must demonstrate that the examining physician reviewed relevant medical records, conducted appropriate physical examination, and applied accepted medical standards in reaching conclusions. Insurance carriers that submit deficient IME reports risk denial of summary judgment even when plaintiffs offer minimal opposition. Courts scrutinize whether IME physicians possessed adequate information and applied proper methodology in assessing treatment necessity.

Case Background: Multiple Specialty IME Reports

In Huntington Regional Chiropractic, P.C. v Truck Ins. Exch., the defendant insurance carrier moved for summary judgment based on lack of medical necessity for chiropractic and related services. The carrier submitted two independent medical examination reports: one from a chiropractor addressing chiropractic treatment and another from an orthopedist evaluating the medical aspects of care. This multi-specialty approach reflected the carrier’s recognition that different types of treatment require evaluation by appropriately credentialed experts.

Both IME reports set forth factual bases and medical rationales supporting conclusions that treatment exceeded medical necessity. The chiropractor’s report analyzed the chiropractic care rendered, evaluated treatment duration and frequency, and explained why continued chiropractic treatment was unnecessary based on the documented injury severity and expected recovery timeline. The orthopedist’s report addressed whether the underlying musculoskeletal injuries warranted the level of intervention provided and whether treatment complied with accepted orthopedic standards.

The plaintiff healthcare provider opposed the motion by submitting medical affidavits from treating physicians. These affidavits countered the IME conclusions by explaining why treatment was medically necessary based on clinical findings documented in contemporaneous treatment records. The Appellate Term found that the plaintiff’s medical affidavits raised triable issues of fact sufficient to defeat summary judgment, despite the carrier’s submission of two specialty-specific IME reports.

Jason Tenenbaum’s Analysis:

Huntington Regional Chiropractic, P.C. v Truck Ins. Exch., 2015 NY Slip Op 51068(U)(App. Term 2d Dept. 2015)

“In support of its motion, defendant submitted, among other things, two independent medical examination reports, one from a chiropractor and one from an orthopedist, which set forth a factual basis and a medical rationale for the examiners’ determination that there was a lack of medical necessity for the respective services provided (see Total Equip., LLC v Praetorian Ins. Co., 34 Misc 3d 145, 2012 NY Slip Op 50155 ). However, the medical affidavits submitted by plaintiffs in opposition were sufficient to raise a triable issue of fact as to the medical necessity of the claims at issue”

Were there contemporaneous notes? Was there anything in admissible form? Did Defendant preserve appropriate hearsay and other evidentiary objections?

Legal Significance: Evidentiary Standards and Burden Dynamics

The Huntington Regional Chiropractic decision underscores the adversarial nature of medical necessity determinations and the critical importance of evidentiary quality on both sides. Insurance carriers cannot simply submit IME reports and expect automatic summary judgment. When plaintiffs respond with competent medical evidence explaining why treatment was necessary, factual disputes emerge that require trial resolution through witness credibility assessments and weight-of-evidence determinations.

The decision also implicates fundamental questions about evidence admissibility that Jason Tenenbaum identifies: Were there contemporaneous treatment notes supporting the plaintiff’s position? Was evidence submitted in admissible form satisfying business record requirements? Did the defendant preserve appropriate hearsay and evidentiary objections? These procedural considerations often determine outcomes in medical necessity cases because courts cannot consider inadmissible evidence on summary judgment motions.

Healthcare providers defending against medical necessity challenges must ensure their opposition evidence satisfies CPLR 3212 standards. Affidavits from treating physicians should reference specific examination findings documented in contemporaneous records rather than offering retrospective opinions unsupported by contemporaneous documentation. The affidavits should address the IME reports directly, identifying factual errors or analytical flaws in the reviewer’s reasoning.

Practical Implications: Strategic Considerations for Both Sides

For insurance carriers, the Huntington Regional Chiropractic outcome demonstrates that merely obtaining IME reports from appropriately credentialed physicians does not guarantee summary judgment. Carriers should ensure IME physicians review comprehensive medical records, conduct thorough examinations, and explain their conclusions with reference to specific clinical findings and accepted medical standards. The IME report should anticipate and preemptively address arguments the treating physician might raise.

Carriers should also consider whether to seek discovery of contemporaneous treatment notes before moving for summary judgment. If treatment records lack documentation supporting medical necessity, the plaintiff may struggle to defeat summary judgment even with affidavits from treating physicians. Strategic use of verification demands under 11 NYCRR § 65-3.5(a) can identify documentation gaps before substantial motion practice expenditure.

For healthcare providers, the decision reinforces the importance of maintaining detailed contemporaneous treatment records. When IME challenges arise, providers cannot reconstruct medical necessity through affidavits alone if contemporaneous records fail to document clinical findings supporting treatment decisions. Thorough documentation at the time of service provides the evidentiary foundation necessary to rebut IME conclusions.

Providers should also carefully scrutinize IME reports for foundational deficiencies, methodological errors, or analytical gaps. If the IME physician mischaracterized records, overlooked relevant clinical findings, or applied incorrect medical standards, the provider’s opposition papers should highlight these deficiencies. Evidentiary objections regarding hearsay, lack of personal knowledge, or inadequate foundation should be preserved to prevent the court from considering deficient evidence.

Key Takeaway

This decision highlights critical procedural considerations in medical necessity disputes. While well-documented IME reports from appropriately credentialed physicians can establish prima facie entitlement to summary judgment, healthcare providers can effectively counter with proper medical affidavits from treating physicians that create triable issues of fact. The case raises important questions about evidence foundation requirements, contemporaneous documentation standards, and whether defendants adequately preserve evidentiary objections. Successful litigation of medical necessity cases requires attention to both substantive medical analysis and procedural evidence rules, with outcomes often turning on admissibility determinations and the quality of contemporaneous treatment documentation rather than retrospective expert opinions alone.

Legal Update (February 2026): Since this post’s publication in 2015, New York’s medical necessity standards under Insurance Law § 5106 may have been subject to regulatory amendments, updated examination protocols, or revised evidentiary requirements for IME reports. Practitioners should verify current provisions regarding medical necessity determinations, as procedural requirements and documentation standards for both insurers and healthcare providers may have evolved significantly over the past decade.