Understanding New York No-Fault Insurance Medical Necessity: Why Surgery Peer Review Alone Is Not Enough

Understanding No-Fault Insurance Medical Necessity Claims in New York

A peer review does not fail simply because it is a peer review. The question in Allstate v Buffalo Neurosurgery Group was whether the reports submitted on that motion established that the surgery was unnecessary. The court found they did not.

What the 2019 court actually decided

Allstate Ins. Co. v Buffalo Neurosurgery Group, 172 AD3d 967 (2019) concerned spinal-fusion benefits. After the provider prevailed in arbitration and before the master arbitrator, Allstate brought a de novo action under Insurance Law § 5106(c). It was a new determination of the claim, not ordinary review of an arbitration award.

The Second Department left the medical-necessity branch of Allstate’s summary-judgment motion denied. Because Allstate had not met its initial burden, the court did not need to assess the provider’s opposition on that issue. But the insurer won its separate fee-schedule branch, and the provider’s summary judgment was removed. Calling the case an outright provider victory misses that split result.

Reading the reports and the opposition

Amherst Medical Supply v A. Central, 2013 NY Slip Op 51800(U), cited in Allstate, shows a concrete failure of proof. The reviewer said the equipment was unnecessary without supplying a factual basis or medical rationale. The treating chiropractor also explained the conditions being treated and the intended benefit of each item.

A motion can also fail after the insurer makes that showing. In AutoOne v Eastern Island Medical Care, 136 AD3d 722 (2016), the insurer established timely denials and made its initial medical showing. The provider then raised a factual dispute through affidavits and treatment records. The motion still failed, but not because the insurer’s initial proof was inadequate.

Default judgments involve a different burden. Global Liberty v W. Joseph Gorum, 143 AD3d 768 (2016) involved separate claims: an affirmed peer review supported the facts needed for a default judgment against one provider, while the evidence against another did not establish lack of medical necessity on summary judgment. Do not treat those burdens as interchangeable.

Latest developments

Still current (September 2026): American Transit v Beach Medical Rehabilitation, 250 AD3d 870 (2026) confirms that denial timing and the claimed medical defense must be examined separately in a de novo no-fault action.

The insurer did not establish timely mailing of its denials, so its medical-necessity defense was precluded. Lack of causation remained available despite the late denial. That defense nevertheless failed: the peer-review evidence did not address the full treatment record or specifically connect its reasoning to whether the accident caused the injuries. The provider obtained summary judgment and confirmation of its master arbitration award.

Keep the order of those rulings in view. Its criticism of the peer-review evidence addressed causation after medical necessity was already precluded. It did not announce that every peer review is insufficient, or impose a clear-and-convincing-evidence standard.

Cases in this topic

The directory links 105 related archive notes; this overview brings the cohort to 106. Dates below are the notes’ publication dates. The entries preserve discussion written at the time, including criticism and procedural arguments. They are not a statement that every older passage describes current law.

The insurer’s initial medical showing

Start here for the evidence offered to support or resist a medical-necessity defense. A report sufficient to raise a factual dispute does not necessarily establish entitlement to judgment.

• Easy Care/A. Central: findings left unexplained by the reviewer — 2015-07-21
• PF-NCT: dated commentary on testing, coding and overlapping studies — 2014-10-14
• Shirom: the report addressed a different treatment period — 2014-09-24
• Amherst: an unsupported conclusion about medical supplies — 2013-11-03
• Synergy: the reviewer’s stated MUA protocol and the opposition — 2013-07-07
• Park Slope/Praetorian: equipment considered superfluous to existing therapy — 2013-05-16
• Amherst/NYCM: identifying what the medical file was missing — 2013-04-21
• Devonshire: conclusory proof in opposition to payment — 2011-04-08
• Pomona/GEICO: an issue of fact is not judgment as a matter of law — 2011-03-03
• Enko: equipment and concurrent treatment — 2011-01-03
• Alur: a supported peer review shifts the burden — 2010-04-25
• B.Y., M.D.: expert proof and reverse summary judgment — 2010-02-06
• A-minus/Mercury: dated commentary on appellate treatment of medical proof — 2009-05-02

When opposition does—or does not—raise an issue

These records produced different outcomes. Read the opposing evidence alongside the report it was meant to answer; the fact that a document is called a letter of medical necessity does not settle the issue.

• DRD Medical: competing physical-therapy opinions — 2020-04-27
• Forest Drugs: an affirmation that did not answer the examiner — 2018-11-30
• Five Boro/A. Central: describing the intended benefits of supplies — 2016-03-30
• Rosenzweig: opposition to a peer review of treatment — 2016-03-21
• Throgs Neck and South Nassau: contrasting rebuttal results — 2015-12-07
• Bronx Mega Care: failure to address IME conclusions — 2015-07-21
• Huntington Regional: affidavits responding to two examinations — 2015-07-21
• Westcan: a rebuttal that raised a factual dispute — 2015-07-21
• Five Boro Medical: attorney argument and reviewer qualifications — 2015-01-03
• Promed and Quality Health: two medical-necessity reversals — 2014-08-20
• Plutno: different results for fees and continued treatment — 2014-03-25
• AP Diagnostic: explaining why an MRI was requested — 2013-10-20
• Hunt City: conflicting chiropractic opinions — 2013-10-20
• Promed Durable: equipment, existing therapy and opposing proof — 2013-08-27
• Brooklyn Chiropractic: a second examination and a separate peer-review claim — 2013-06-11
• All Boro/Progressive: a letter and testimony from a different matter — 2013-02-24
• Ocean Diagnostic: medical evidence the insurer had not addressed — 2012-06-27
• New Life: answering two peer-review reports — 2012-06-18
• Neomy: explaining the need for additional studies — 2012-05-05
• Complete Radiology: a treating physician’s letter — 2012-03-12
• Darlington: generic conclusions without a medical foundation — 2012-02-17
• Neomy/GEICO: an affidavit raising a factual dispute — 2012-02-03
• Diagnostic Medicine: attorney argument without medical evidence — 2012-01-27
• Total Equipment and Elmont: opposition to supported motions — 2012-01-27
• Triangle R: medical supplies and the provider’s opposition — 2011-09-13
• Park Slope/GEICO: competing medical submissions — 2011-02-21
• Elmont and Dynamic: unrebutted medical submissions — 2010-12-01
• Richmond, Radiology Today and Delta: rebuttal and form objections — 2010-11-27
• Mutual Care and related cases: applying Pan Chiropractic — 2010-10-08
• Innovative Chiropractic: reaffirming an opinion without answering the reviewers — 2010-05-23
• Quality Psychological: the examining psychologist’s letter — 2010-04-13
• Prime Psychological: the limits of an opposing affirmation — 2010-04-11
• GZ Medical: an inadequate medical affidavit — 2010-03-26
• High Quality: addressing the peer reviewer’s reasoning — 2010-03-18
• Eastern Star: opposition to an IME-based motion — 2010-03-12
• Innovative Chiropractic/Travelers: conclusory opposition — 2009-12-09
• Innovative Chiropractic/Mercury: responding to IME findings — 2009-11-17
• Pan Chiropractic: the original 2009 rebuttal decision — 2009-07-16
• Bronze Acupuncture: conclusory opposition compared with Park Slope — 2009-06-18
• Park Slope/NYCM: the 2009 debate over sufficient opposition — 2009-03-19

IME findings and continued treatment

These notes concern findings after an examination, rather than a failure to attend one. The two Amato entries preserve the trial-court discussion and the later appellate reversal.

• Mingmen: normal findings and the provider’s response — 2018-09-29
• Ji Sung Kim: an IME distinguishing physical therapy from acupuncture — 2016-06-11
• Arnica: the supervising acupuncturist’s response to the IME — 2016-03-02
• Mendoza: opposition to normal IME findings — 2015-06-22
• Gaetane: an affidavit without an examination or medical rebuttal — 2015-05-27
• V.S. Care: acupuncture cutoff and notice to the provider — 2015-03-26
• Glenn Segal: responding to both IME reports — 2014-08-29
• Triumph: separate fee-schedule and IME-cutoff issues — 2014-06-09
• Total Equipment/Mercury: equipment and the cutoff date — 2014-01-06
• Premier Health: explaining why injuries had resolved — 2013-11-03
• Amato: the 2013 appellate reversal and the earlier snapshot reasoning — 2013-07-16
• Goldman: services predating the examination — 2012-07-17
• Amato: the original 2010 trial-court discussion of an IME snapshot — 2010-10-27

Report form, disclosure and supporting records

The procedural setting matters: obtaining a report, submitting motion evidence and proving a defense at trial are different questions. Statements about who could affirm in older notes need to be read with the current CPLR 2106 text.

• Innovative MR: unsigned and unsworn letters in the 2015 record — 2015-10-06
• Eagle Surgical: exclusion of records for lack of an authorization — 2013-11-18
• A Quality: obtaining the report versus proving a defense — 2013-04-01
• Innovative MR: the 2013 letter and its substantive shortcomings — 2013-02-24
• Five Boro Psychological: reviewed records and the motion papers — 2012-06-08
• Ortho-Med: whether reviewed records had to accompany the motion — 2012-02-03
• Neomy/GEICO: the reviewed-records and hearsay arguments — 2011-08-18
• Elmont/NYCM: the appellate ruling on reviewed records — 2010-12-27
• Elmont Open MRI: the archive’s peer-review discussion — 2010-05-15
• Exclusive Medical: the motion’s expert submissions — 2009-11-12
• Continental Medical: an unsworn, unread report in the 2009 record — 2009-02-26

Trial testimony and substitute reviewers

Some entries report appellate decisions; others preserve trial-court reasoning or Jason’s contemporary criticism. A witness’s qualifications and the credibility of the testimony are separate issues.

• Mollo: the competing accounts of manipulation under anesthesia — 2021-03-17
• Parkway Hospital: the insurer’s trial burden and witness credibility — 2019-08-04
• Manipulation under anesthesia: competing trial testimony — 2018-07-07
• Radiology Today/GEICO: a substitute witness and the original report — 2017-12-26
• Surgicare: surgery, therapy notes and the trial record — 2017-10-28
• Promed Orthocare: a substitute expert and a new trial — 2017-10-02
• Metropolitan Diagnostic: qualifications, credibility and the verdict — 2016-12-29
• Substitute IME witnesses: Jason’s original request for practitioners’ views — 2016-03-30
• Dayan: the medical-necessity burden at trial — 2015-12-07
• AP Orthopedic: review of a medical-necessity verdict — 2015-11-28
• All-In-One: the original debate about stipulated treatment records — 2014-04-14
• All Borough: independent expert review at trial — 2014-04-02
• Webster Avenue: unopposed testimony the court did not credit — 2014-03-26
• Drew De Marco: qualifications to testify about manipulation under anesthesia — 2013-12-28
• Radiology Today/Travelers: testimony without a medical rationale — 2013-05-29
• Bajaj: substitute-peer testimony in the trial court — 2012-06-23
• Park Slope/Progressive: a substitute witness and the dissent — 2012-03-02
• All Boro: stipulated evidence and an unavailable witness — 2012-02-03
• PSW: the trial court’s assessment of the insurer’s witness — 2011-09-26
• Radiology Today: allowing a substitute reviewer to testify — 2011-09-26
• Elmont/State Farm: the trial court’s expert-foundation ruling — 2010-01-21
• Krishna: additional documents and the scope of expert testimony — 2009-07-01
• The early four-corners debate over denial grounds — 2008-10-15

Denial timing and motion procedure

These notes put medical proof alongside the mailing record, the relief requested on the motion, or the pending discovery.

• Hernandez: unpaid benefits and the insurer’s opposition — 2022-07-07
• Healing Art: limits on searching the summary-judgment record — 2015-11-28
• Medical Arts: discovery while a medical-necessity motion is pending — 2015-07-21
• Easy Care: mailing-vendor proof and medical rationale — 2014-12-23

A New Jersey medical-necessity comparison

This is a New Jersey arbitration discussion. It is included for comparison, not as authority for New York procedure.

• Prospect Medical: New Jersey review of MUA arbitration — 2011-07-10

Connect to the Encyclopedia

Browse the Legal Encyclopedia for the related no-fault and evidence topics. These archive notes address the next questions raised by the cases above:

• Amherst: why the equipment review fell short
• Pan Chiropractic: responding to medical proof
• High Quality: the substance of a rebuttal
• Ortho-Med: reviewed records and the motion papers
• Amato: the appellate treatment of an IME cutoff
• Midtown Medical: an inadequate report

Questions about a disputed no-fault bill? Contact the firm to discuss the claim and the available records.