June 8, 2006

Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51185(U))

https://www.beynensonlaw.com/case-law/elmont-open-mri-diagnostic-radiology-p-c-v-geico-ins-co-2006-ny-slip-op-51185u/

Court: Appellate Term, Second Department
Decided: June 8, 2006
Citation: 2006 NY Slip Op 51185(U) · 12 Misc 3d 133(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co., 12 Misc 3d 133(A), 2006 NY Slip Op 51185(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2006)

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.

A medical necessity denial must state the factual basis and medical rationale with sufficient particularity, even when timely issued. The provider sought summary judgment for assigned no-fault benefits for medical services, and the insurer relied on a timely denial based on a peer review. The review's conclusions lacked a sufficient factual foundation and medical rationale to warrant rejection of the claims. The insurer therefore failed to raise a triable issue of fact supporting its medical necessity defense. The Appellate Term, Second Department, reversed the order denying the provider's motion, granted summary judgment and remanded for statutory interest and attorney's fees under Insurance Law § 5106 (a) and the implementing regulations.

Reported in New York Official Reports at Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51185(U))

[*1]

Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co.

2006 NY Slip Op 51185(U) [12 Misc 3d 133(A)]

Decided on June 8, 2006

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This opinion is uncorrected and will not be published in the printed Official Reports.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 June 8, 2006

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : RUDOLPH, P.J., TANENBAUM and LIPPMAN, JJ
2005-669 N C.

Elmont Open MRI and Diagnostic Radiology, P.C., d/b/a All County Open MRI and Diagnostic Radiology, as Assignee of Tao Sau Yeung, Appellant,
against
GEICO Insurance Company, Respondent.

Appeal from an order of the District Court of Nassau County, First District (Scott Fairgrieve, J.), dated September 30, 2004. The order denied plaintiff’s motion for summary judgment.

Order reversed without costs, plaintiff’s motion for summary judgment granted and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees.

In this action to recover first-party no-fault benefits for medical services rendered to its assignor, defendant timely denied the claims on the ground of lack of medical necessity. A timely denial alone, however, does not avoid preclusion where said denial is factually insufficient, conclusory or vague, and an insurer seeking to deny benefits based on lack of medical necessity must set forth with sufficient particularity the factual basis and medical rationale underlying that determination (see A. B. Med. Servs. PLLC v Liberty Mut. Ins. Co., 10 Misc 3d 128[A], 2005 NY Slip Op 51902[U] [App Term, 2d & 11th Jud Dists]; Amaze Med. Supply v Allstate Ins. Co., 3 Misc 3d 43, 44 [App Term, 2d & 11th Jud Dists 2004]). In the instant case, the conclusions of the peer review upon which the denial was based were not supported by a sufficient factual foundation and medical rationale to warrant rejection of the claims and, accordingly, were insufficient to support a defense of lack of medical necessity (see Park Neurological Servs. P.C. v GEICO Ins., 4 Misc 3d 95 [App Term, 9th & 10th Jud Dists 2004]; see also A.B. Med. Servs. PLLC v American Mfrs. Mut. Ins. Co., 6 Misc 3d 133[A], 2005 NY Slip Op 50114[U] [App Term, 2d & 11th Jud Dists]; cf. Amaze Med. Supply Inc. v [*2]Travelers Prop. Cas. Corp., 7 Misc 3d 128[A], 2005 NY Slip Op 50452[U] [App Term, 2d & 11th Jud Dists]). Under the circumstances, defendant has failed to raise a triable issue of fact.

Accordingly, summary judgment is granted in favor of plaintiff and the matter is remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

Rudolph, P.J., Tanenbaum and Lippman, JJ., concur.
Decision Date: June 8, 2006

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 medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)

Held the peer review's conclusions lacked a sufficient factual foundation and medical rationale, so they could not support the defense and raised no triable issue, and granted the provider summary judgment.

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

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 109 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (2005 NY Slip Op 51902(U)) FollowedA sufficient peer review report cannot cure a denial that omits the factual basis and medical rationale for lack of medical necessity.
Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 24119)An insurer may not deny equipment fees as exceeding local prevailing rates when the applicable schedule limits reimbursement to 150% of cost.
Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210) FollowedThe insurer's denial did not set forth a factual basis and medical rationale for lack of medical necessity, precluding its medical-necessity defense.
A.B. Med. Servs. PLLC v American Mfrs. Mut. Ins. Co. (2005 NY Slip Op 50114(U))An insurer cannot defeat summary judgment with a peer review citing insufficient information without showing it sought verification.
Amaze Med. Supply Inc. v Travelers Prop. Cas. Corp. (2005 NY Slip Op 50452(U)) Contrasted (cf., but see)An insurer need not seek further verification when a peer review finds no substantiation of equipment's medical necessity in documents obtained for review.

Similar decisions

Elmont Open MRI & Diagnostic Radiology, P.C. v Tri-State Ins. Co. (2012 NY Slip Op 50170(U))An insurer need not annex the medical records reviewed by its peer review doctor to establish lack of medical necessity.
All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co. (2006 NY Slip Op 50318(U))A peer review citing insufficient information cannot support denial without proof that the insurer sought that information through verification.
Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52061(U))The insurer's affirmed peer review established lack of medical necessity, and the provider failed to raise a triable medical issue.
Elmont Open MRI & Diagnostic Radiology, P.C. v Tri State Consumer Ins. Co. (2012 NY Slip Op 50079(U))The provider failed to submit medical evidence raising a triable issue in response to the insurer's sufficient medical-necessity peer review.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50829(U))The insurer's affirmed peer reviews raised a triable issue of medical necessity and defeated the provider's summary judgment motion.