Key Takeaway
A key New York no-fault case showing how IME reports can establish lack of medical necessity even when acknowledging ongoing disabilities and need for some treatment.
In New York’s no-fault insurance system, disputes over medical necessity frequently hinge on the quality and specificity of Independent Medical Examination (IME) reports. Healthcare providers seeking payment for services must demonstrate that their treatments are medically necessary, while insurance carriers often rely on IME examinations to challenge such claims.
The case discussed below illustrates an important principle: an IME doctor doesn’t need to conclude that a patient requires no treatment whatsoever to establish lack of medical necessity for specific services. Instead, the focus is on whether the particular treatment modality in question is necessary, even when other forms of treatment may be appropriate.
This distinction has become increasingly significant in the post-Arnica legal landscape, where courts have raised the bar for what constitutes sufficient rebuttal evidence against IME findings.
Jason Tenenbaum’s Analysis:
Ji Sung Kim Acupuncture, P.C. v American Tr. Ins. Co., 2016 NY Slip Op 50873(U)(App. Term 2d Dept. 2016)
“The IME report set forth a factual basis and medical rationale for the doctor’s conclusion that there was a lack of medical necessity for further treatment. In opposition to the motion, plaintiff submitted an affidavit from plaintiff’s owner who had treated plaintiff, which failed to meaningfully refer to, [*2]let alone sufficiently rebut, the conclusions set forth in the doctor’s report”
This was my case so therefore I am posting it. More importantly, this case is interesting because the IME report stated that the person still had disabilities and that further PT was appropriate. Dr. Cole stated that further acupuncture would not be necessary. This was sufficient to prove lack of medical necessity.
The discusses why the IME is wrong; that acupuncture would help the patient and that upon a review of the chart, the acupuncture treatment was helpful. In years passed, this would have been enough to raise an issue of fact. I believe in the post Arnica v. Interboard world, things are different now.
Key Takeaway
This case demonstrates that IME reports can successfully establish lack of medical necessity for specific treatments even when acknowledging ongoing disabilities. The court found that distinguishing between different treatment modalities—approving physical therapy while rejecting acupuncture—provided sufficient medical rationale. Healthcare providers must now present more robust rebuttal evidence than previously required to overcome IME determinations.
