March 16, 2007

Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2007 NY Slip Op 50988(U))

Headnote

The court considered the case of a provider seeking to recover first-party no-fault benefits for an MRI provided to its assignor. The provider filed a motion for summary judgment, which was denied by the court due to a peer review report created by the defendant that raised a triable issue of the MRI's medical necessity. The defendant had informed the provider that the processing of the claim would be delayed until confirmation of medical necessity was received, and after receiving the verification, the denial was issued based on the peer review report. The main issue decided was the defendant's failure to seek verification directly from the plaintiff, as required by regulations. The court upheld the denial of the provider's motion for summary judgment and affirmed the lower court's decision, stating that the argument was rejected for the same reasons provided in another similar case.

Reported in New York Official Reports at Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2007 NY Slip Op 50988(U))

Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2007 NY Slip Op 50988(U)) [*1]

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

2007 NY Slip Op 50988(U) [15 Misc 3d 139(A)]

Decided on March 16, 2007

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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 16, 2007

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : RUDOLPH, P.J., TANENBAUM and LaCAVA, JJ
2006-166 N C.

Elmont Open Mri & Diagnostic Radiology, P.C. d/b/a ALL COUNTY OPEN MRI & DIAGNOSTIC RADIOLOGY as assignee of RENE DECLERCQ, Appellant,
against
State Farm Insurance Company, Respondent.

Appeal from an order of the District Court of Nassau County, First District (Sharon Commissiong, J.), entered April 19, 2005. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment.

Order, insofar as appealed from, affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits for an MRI provided its assignor, the court denied plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment on the ground that defendant’s peer review report created a triable issue of the MRI’s medical necessity. After receiving plaintiff’s claim, defendant informed plaintiff by letter that the claim’s “processing” would be delayed pending receipt of “confirmation of medical necessity
from the referring physician.” Defendant received the verification 13 days later and issued its denial 30 days thereafter on the basis of the peer review report which was compiled, in part, on information received from the physician.

Plaintiff objects only to defendant’s failure to seek the verification directly from plaintiff as, plaintiff insists, the regulations require. The court below rejected the argument and we affirm for the reasons set forth in Doshi Diagnostic Imaging Servs. v State Farm Insurance (___ Misc 3d ___, 2007 NY Slip Op _______, decided herewith). [*2]

Rudolph, P.J., Tanenbaum and LaCava, JJ., concur.
Decision Date: March 16, 2007