Verdict in favor of Plaintiff sustained

The Critical Role of Credibility in Medical Necessity Trials

In no-fault insurance litigation, medical necessity determinations often hinge on expert testimony from physicians who review treatment records and opine whether the services provided were appropriate and necessary. While professional qualifications establish that a physician may testify as an expert, the ultimate question before the trier of fact centers on credibility: does the court believe the expert’s testimony? This distinction between competency to testify and credibility of testimony proves crucial in medical necessity trials.

New York’s appellate courts have consistently held that credibility determinations rest within the province of the trier of fact. When a trial court observes a witness testify, evaluates demeanor, considers the logical consistency of testimony, and weighs the expert’s methodology and reasoning, that court occupies a superior position to assess credibility compared to appellate courts reviewing a cold record. Consequently, appellate courts afford significant deference to trial court credibility findings, disturbing them only when they lack any reasonable basis in the record.

In medical necessity cases involving MRI studies, defendants frequently rely on orthopedic surgeons to challenge the necessity of imaging ordered by other specialists. The question whether an orthopedic surgeon can opine on imaging necessity raises both competency and weight issues that trial courts must carefully navigate.

Case Background and Procedural History

Metropolitan Diagnostic Med. Care, P.C. v Erie Ins. Co. of N.Y., 2016 NY Slip Op 51815(U) (1st Dept. 2016)

Facts

(1) At a nonjury trial of this action by a provider to recover assigned first-party no-fault benefits, the sole issue was the medical necessity of the MRIs of plaintiff’s assignor’s cervical and thoracic spines. The only witness was defendant’s doctor, a board-certified orthopedic surgeon with 30 years of experience, who also “write papers, and give lectures.

(2) The Civil Court, finding that defendant’s medical witness was not qualified as an expert and, in any event, that the witness’s testimony was not credible, awarded judgment in favor of plaintiff in the principal sum of $1,839.34.

Analysis

(1) The fact that defendant’s witness was an orthopedic surgeon and the MRIs at issue were prescribed by a doctor whose specialty is physical medicine and rehabilitation goes to the weight to be given to the testimony and not, contrary to the Civil Court’s determination, to the witness’s competency to testify as an expert

(2) “However, we find no basis to disturb the Civil Court’s finding that the witness’s testimony was not credible.”

My thoughts

The most recent theme running through these medical necessity trials is that the doctor is (or is not) credible. Upon the fact-finder making that threshold finding, the appeal will sink or swim.

Legal Significance: Competency Versus Credibility

The Appellate Term’s decision in Metropolitan Diagnostic Med. Care establishes an important distinction in the law of expert testimony. The Civil Court initially ruled that the defendant’s orthopedic surgeon expert was not qualified to testify regarding the medical necessity of MRI studies ordered by a physical medicine and rehabilitation specialist. This competency ruling would have precluded consideration of the expert’s testimony entirely.

The Appellate Term corrected this legal error, holding that the orthopedic surgeon’s qualifications were sufficient to permit testimony as an expert. The fact that the prescribing physician specialized in physical medicine and rehabilitation while the defense expert specialized in orthopedic surgery affected the weight to be given to the testimony, not the competency to offer expert opinions. This distinction matters because a witness found incompetent to testify as an expert cannot offer opinion testimony at all, while a competent expert whose testimony receives little weight may still provide some probative value.

However, the Appellate Term’s correction of this legal error did not affect the ultimate outcome. Despite finding that the orthopedic surgeon was qualified to testify as an expert, the appellate court upheld the trial court’s determination that the expert’s testimony lacked credibility. This credibility finding proved dispositive, as it left the defendant without credible proof that the MRI studies were unnecessary.

The decision demonstrates the limited scope of appellate review of credibility determinations. The Appellate Term stated it found “no basis to disturb” the credibility finding, employing language that signals substantial deference to the trial court’s assessment. Even when an appellate court might have evaluated credibility differently, it will not substitute its judgment for that of the trial court absent clear error or lack of evidentiary support.

Practical Implications for Medical Necessity Litigation

As Jason Tenenbaum astutely observes, credibility has emerged as the dominant theme in medical necessity trials. This trend carries significant practical implications for both plaintiffs and defendants in no-fault litigation. For defendants challenging medical necessity, merely presenting a qualified expert witness proves insufficient. The expert must testify credibly, with clear methodology, consistent reasoning, and persuasive explanations for why the challenged treatment was unnecessary.

Several factors commonly affect expert credibility in medical necessity cases. First, experts who fail to review complete medical records or who base opinions on partial information face credibility challenges. Second, experts whose testimony contains internal contradictions or who cannot explain apparent inconsistencies undermine their own credibility. Third, experts who appear to function as litigation advocates rather than impartial medical evaluators often receive skeptical reception from trial courts. Fourth, experts whose testimony reflects superficial analysis or cursory review may lack the persuasiveness necessary to meet the defendant’s burden of proof.

For plaintiffs, this decision offers encouragement that trial courts will carefully scrutinize defense expert testimony rather than accepting it uncritically based solely on professional credentials. A board-certified orthopedic surgeon with 30 years of experience who writes papers and gives lectures might appear formidable on paper, yet those qualifications do not guarantee credible testimony. If the trial testimony reveals weaknesses in methodology, reasoning, or factual foundation, even highly credentialed experts may prove unpersuasive.

The decision also underscores the importance of trial preparation and presentation. Because credibility determinations often prove dispositive and receive substantial appellate deference, the trial itself—not the appeal—represents the critical battleground in medical necessity cases. Cross-examination that exposes weaknesses in expert testimony, careful development of foundational facts, and effective impeachment techniques can all influence the trial court’s credibility assessment.

Finally, this case illustrates the challenge defendants face in medical necessity litigation. The burden rests on the defendant to prove that challenged treatment was unnecessary. When the defendant’s expert testimony lacks credibility, this burden cannot be met, regardless of the expert’s impressive qualifications. As Tenenbaum notes, once the fact-finder makes the threshold credibility determination, the appeal will “sink or swim” based on that finding. This reality emphasizes the importance of thorough expert preparation, honest testimony, and credible presentation at the trial level.

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• Civil Court Decisions in No-Fault Insurance: When Legal Reasoning Goes Wrong
• A prima facie case of medical necessity?
• New York No-Fault Insurance Law