Key Takeaway
New York court decision on medical necessity and fee schedule defenses in no-fault insurance cases, featuring expert affidavit requirements and proper coding analysis.
Jaga Med. Servs., P.C. v American Tr. Ins. Co., 2017 NY Slip Op 50954(U)(App. Term 2d Dept. 2017)
(1) “In opposition to those branches of defendant’s cross motion, plaintiff submitted an affidavit from a doctor 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 Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]).”
(2) “Contrary to plaintiff’s contention, the affidavit executed by defendant’s expert professional coder, submitted in support of the branches of defendant’s cross motion seeking summary judgment dismissing the first, second and fifth causes of action, established that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services at issue in these causes of action (see e.g. Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129, 2016 NY Slip Op 51359 ).”
Interesting observation from the motion papers.
(1) Peer review involved EMG/NCV: The opposition affidavit did not seem bad. While it said a lot, however, it was totally not responsive to the peer report.
(2) Expert analysis involved ROM and MMT: Payable per extremity and trunk. The review again recommended less than what was actually paid. There was no fee schedule opposition.
Related Articles
- Understanding medical necessity disputes in major medical cases
- Why conclusory affidavits fail in medical necessity summary judgment motions
- When comp defense succeeds but medical necessity defense falters
- Ground rule 11 and the IME cut off in fee schedule cases
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2017 decision, New York’s no-fault fee schedules and reimbursement regulations have undergone multiple revisions, including potential updates to workers’ compensation fee schedule cross-references and medical necessity determination procedures. Practitioners should verify current fee schedule provisions and peer review standards, as regulatory amendments may have modified the reimbursement methodologies and expert affidavit requirements discussed in this case.
