July 16, 2010

Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 51246(U))

https://www.beynensonlaw.com/case-law/hillcrest-radiology-assoc-v-state-farm-mut-auto-ins-co-2010-ny-slip-op51246u/

Court: Appellate Term, Second Department
Decided: July 16, 2010
Citation: 2010 NY Slip Op 51246(U) · 28 Misc 3d 129(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co., 28 Misc 3d 129(A), 2010 NY Slip Op 51246(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

The insurer's affirmed peer review established lack of medical necessity, and the provider failed to rebut that showing. In the provider's action for assigned no-fault benefits, the insurer moved for summary judgment dismissing the complaint. The provider did not dispute that the claim had been timely denied on medical necessity grounds. The peer review supplied a factual basis and medical rationale for concluding that the services were not medically necessary. The Appellate Term, Second Department, affirmed the order granting the insurer's motion, finding the provider's remaining contentions without merit.

Reported in New York Official Reports at Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 51246(U))

[*1]

Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co.

2010 NY Slip Op 51246(U) [28 Misc 3d 129(A)]

Decided on July 16, 2010

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on July 16, 2010

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., WESTON and GOLIA, JJ
2009-739 K C.

Hillcrest Radiology Associates a/a/o Leroy Stewart, Appellant,
against
State Farm Mutual Automobile Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Lila Gold, J.), entered November 21, 2008. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground of lack of medical necessity. The Civil Court granted defendant’s motion, and the instant appeal ensued.

Plaintiff does not dispute that defendant established that it had timely denied the claim at issue on the ground of lack of medical necessity. In addition, in support of its motion for summary judgment, defendant submitted an affirmed peer review report setting forth a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the medical services at issue. Defendant’s showing that the services at issue were not medically necessary was unrebutted by plaintiff. Therefore, defendant’s motion for summary was properly granted (see e.g. Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., [*2]16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

In view of the foregoing, and as plaintiff’s remaining contentions lack merit, the order is affirmed.

Pesce, P.J., Weston and Golia, JJ., concur.
Decision Date: July 16, 2010

Legal questions

A question of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

Lack of medical necessity

Open the full map

Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Insurer's proof established lack of medical necessity and the provider failed to rebut it

Held the insurer's affirmed peer review report, with a factual basis and medical rationale, established lack of medical necessity and was unrebutted by the provider, so summary judgment for the insurer was proper.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Cited in this decision

Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U))The insurer's examining physician supplied an unrebutted factual basis and medical rationale that the billed MRI was unnecessary.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.

Similar decisions

Complete Radiology, P.C. v Geico Ins. Co. (2012 NY Slip Op 50752(U))The insurer's affirmed peer reviews supplied a factual basis and medical rationale for finding the services medically unnecessary.
Complete Radiology, P.C. v Progressive Ins. Co. (2011 NY Slip Op 52015(U))The insurer's peer review report raised a triable issue of medical necessity and defeated the provider's summary judgment motion.
Radiology Imaging of Queens v Progressive Ins. (2011 NY Slip Op 51860(U))The insurer's unopposed peer review and timely denial established entitlement to dismissal for lack of medical necessity.
Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2010 NY Slip Op 52157(U))The insurer's peer reviews established lack of medical necessity, and the provider submitted no written opposition to the cross motion.
Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52388(U))The insurer's affirmed peer review established lack of medical necessity, and the provider failed to raise a triable issue.