February 8, 2007

East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50213(U))

https://www.beynensonlaw.com/case-law/east-coast-acupuncture-servs-p-c-v-american-tr-ins-co-2007-ny-slip-op-50213u/

Court: Appellate Term, First Department
Decided: February 8, 2007
Citation: 2007 NY Slip Op 50213(U) · 14 Misc 3d 135(A)
Posture: Summary judgment
Outcome: Split result
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co., 14 Misc 3d 135(A), 2007 NY Slip Op 50213(U) (App Term, 1st Dept 2007)

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 provider obtained summary judgment on two claims because the insurer's peer review lacked an adequate factual basis and medical rationale. The peer review was insufficient to defeat the provider's prima facie showing on those assigned first-party no-fault claims. For a third claim, however, the insurer's neurologist's IME report raised a triable issue concerning the medical necessity of the billed acupuncture treatments. The Appellate Term, First Department, modified the order to grant the provider partial summary judgment on the two peer-review claims and otherwise affirmed, leaving the third claim unresolved.

Reported in New York Official Reports at East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50213(U))

[*1]

East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co.

2007 NY Slip Op 50213(U) [14 Misc 3d 135(A)]

Decided on February 8, 2007

Appellate Term, First 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This opinion is uncorrected and will not be published in the printed Official Reports.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 February 8, 2007

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: McKEON, P.J., DAVIS, SCHOENFELD, JJ
570443/06.

East Coast Acupuncture Services, P.C.,a/a/o Ali Ahmed, Plaintiff-Appellant, – –
against
American Transit Insurance Company, Defendant-Respondent.

Defendant appeals from an order of the Civil Court of the City of New York, New York County (Eileen Rakower, J.), dated August 15, 2005, which denied its motion for summary judgment.

Order (Eileen Rakower, J.), dated August 15, 2005, modified to grant plaintiff partial summary judgment on its claims in the sums of $1,796.18 and $340; and as so modified, affirmed, without costs.

The peer review report relied upon by defendant in denying plaintiff’s $1,796.18 and $340 first party no-fault claims did not set forth an adequate factual basis and medical rationale for the reviewer’s determinations, and thus, was insufficient to defeat plaintiff’s prima facie showing of entitlement to summary judgment (see Park Neurological Servs. P.C. v GEICO Ins., 4 Misc 3d 95 [2004]).

With respect to plaintiff’s $765 claim, the independent medical examination (IME) report of defendant’s neurologist was sufficient to raise an issue of fact as to the medical necessity of the acupuncture treatments billed for in connection with this claim.

This constitutes the decision and order of the court.
I concurI concurI concur

Decision Date: February 08, 2007

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 report lacked an adequate factual basis and medical rationale, so it could not defeat the provider's showing on two claims, while the neurologist's IME report raised a triable issue on the remaining acupuncture claim.

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 73 decisions on this question in the First Department courts and the Court of Appeals, 22 (this one included) are in the same category.

Cited in this decision

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

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.

Cited by

A label shows how the later decision treated this one.

Devonshire Surgical Facility v American Tr. Ins. Co. (2011 NY Slip Op 50513(U)) FollowedThe insurer's conclusory peer review report failed to raise a triable issue concerning medical necessity.

Similar decisions

Triboro Chiropractic & Acupuncture v Elec. Ins. Co. (2004 NY Slip Op 50215(U))The insurer's peer reviews and the assignor's apparent denial of receiving acupuncture raised factual issues barring partial summary judgment.
Acuhealth Acupuncture, P.C. v Ameriprise Ins. Co. (2017 NY Slip Op 50119(U))The insurer established full payment under the workers' compensation fee schedules and lack of medical necessity for later acupuncture services.
Apple Tree Acupuncture, P.C. v Interboro Ins. Co. (2011 NY Slip Op 52364(U))The insurer's fee-schedule motion relied on a ground absent from its denials, and the provider raised a medical-necessity issue on other claims.
EMA Acupuncture, P.C. v Geico Ins. Co. (2015 NY Slip Op 51400(U))The provider's acupuncturist affidavit failed to meaningfully address or rebut the insurer's IME findings of no medical necessity.
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U))The insurer failed to establish proper mailing of its denials or a sufficient medical basis for denying continued acupuncture treatment.