December 10, 2010

Complete Radiology, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52158(U))

https://www.beynensonlaw.com/case-law/complete-radiology-p-c-v-geico-ins-co-2010-ny-slip-op-52158u/

Court: Appellate Term, Second Department
Decided: December 10, 2010
Citation: 2010 NY Slip Op 52158(U) · 29 Misc 3d 142(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Complete Radiology, P.C. v GEICO Ins. Co., 29 Misc 3d 142(A), 2010 NY Slip Op 52158(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 did not rebut that showing. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's cross motion for summary judgment dismissing the assigned no-fault complaint. Civil Court had limited trial to medical necessity after finding the provider's prima facie case established and the denial timely and proper. The peer review supplied a factual basis and medical rationale for finding the services unnecessary. Together with the undisputed CPLR 3212 (g) finding concerning the denial, that unrebutted evidence entitled the insurer to dismissal.

Reported in New York Official Reports at Complete Radiology, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52158(U))

[*1]

Complete Radiology, P.C. v GEICO Ins. Co.

2010 NY Slip Op 52158(U) [29 Misc 3d 142(A)]

Decided on December 10, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 December 10, 2010

SUPREME COURT OF THE STATE OF NEW YORK

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

PRESENT: : PESCE, P.J., GOLIA and STEINHARDT, JJ
2009-2050 Q C.

Complete Radiology, P.C. as Assignee of JEANENE McGREGOR, Respondent,
against
GEICO Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Rudolph E. Greco, Jr., J.), entered July 24, 2009. The order, insofar as appealed from, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court found that plaintiff had established
its prima facie case, that defendant had demonstrated that it had timely denied plaintiff’s claim and that the sole issue for trial was the medical necessity of the services rendered to plaintiff’s assignor. Defendant appeals from so much of the order as denied its cross motion for summary judgment dismissing the complaint.

In support of its cross motion, defendant submitted, among other things, an affirmed medical peer review report, which set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the medical services at issue. Defendant’s showing that such services were not medically necessary was unrebutted by plaintiff.

In light of the foregoing, and the Civil Court’s CPLR 3212 (g) finding that defendant “established that it issued a timely and proper denial,” a finding which plaintiff does not dispute, [*2]defendant’s cross motion for summary judgment dismissing the complaint should have been granted (see Delta Diagnostic Radiology, 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., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Pesce, P.J., Golia and Steinhardt, JJ., concur.
Decision Date: December 10, 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, setting forth a factual basis and medical rationale, showed the services were not medically necessary, and that showing was unrebutted, so the insurer's cross motion should have been granted.

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

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.
Diagnostic Radiographic Imaging v GEICO Gen. Ins. Co. (2014 NY Slip Op 50869(U))The insurer's unrebutted peer review reports established that the disputed services were not medically necessary.
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.
Advanced Med. Diagnostics of Queens, P.C. v GEICO Ins. Co. (2013 NY Slip Op 52004(U))The insurer's unrebutted sworn peer review established that the services lacked medical necessity.
Richmond Radiology, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52210(U))The insurer's affirmed peer review raised a triable issue of medical necessity despite the provider's challenge to the information reviewed.