Key Takeaway
Court reverses order after plaintiff's affidavit failed to meaningfully rebut defendant's peer review report showing lack of medical necessity for treatment.
In New York no-fault insurance disputes, proving medical necessity requires more than simply submitting medical records or basic affidavits. Insurance carriers frequently challenge treatment claims through peer review reports, which provide detailed medical analysis questioning whether specific procedures were truly necessary. When healthcare providers want to recover payment for denied services, they must present compelling evidence that directly addresses and refutes the insurance company’s medical arguments.
The Rosenzweig decision illustrates a common pitfall in medical necessity reversals cases: failing to properly counter the insurance carrier’s peer review findings. This case involved a manipulation under anesthesia (MUA) procedure where the plaintiff’s rebuttal strategy proved inadequate. Understanding how courts evaluate competing medical evidence is crucial for healthcare providers navigating the no-fault system, as a copy of a peer report is all that is needed to establish a prima facie case for the insurance company.
Jason Tenenbaum’s Analysis:
Rosenzweig v Mercury Cas. Co., 2016 NY Slip Op 50324(U)(App. Term 2d Dept. 2016)
“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. In opposition to defendant’s motion, plaintiff submitted an affidavit which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the peer review report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 ). In view of the foregoing, and as plaintiff has not challenged the Civil Court’s finding, in effect, that defendant is otherwise entitled to judgment, the order, insofar as appealed from, is reversed, and the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted”
This case was an MUA where the rebuttal was predicated upon an an affidavit showing diminished ROM. There was no discussion as to the merits of the peer review. That is what happened here.
Key Takeaway
Simply demonstrating diminished range of motion through an affidavit is insufficient to counter an insurance company’s peer review report in New York No-Fault Insurance Law cases. Healthcare providers must specifically address and rebut the medical conclusions in the peer review to avoid summary judgment dismissal of their claims.
