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

A decision decides this question when it rules on whether the insurer's medical evidence (a sworn peer review report, an IME report, or a medical expert's trial testimony) established that the billed services or supplies were not medically necessary, and/or whether the provider's opposing evidence rebutted that showing. On motions this means the prima facie showing (a factual basis and medical rationale in admissible form), the provider's rebuttal (an expert affidavit that meaningfully refers to and addresses the insurer's report), and whether the insurer's proof at least raises a triable issue against the provider's own motion. At trial it also covers who bears which burden on the defense and whether the insurer's expert testimony and the records it relies on are admissible.

Settled at the Appellate Division, no conflicting department. No Court of Appeals decision in the database decides this question. On motions the rule is consistent across the Second Department Appellate Division and both Appellate Terms. The insurer makes a prima facie showing with a sworn or affirmed peer review or IME report that sets out a factual basis and medical rationale. That report also raises a triable issue against the provider's motion. The provider rebuts with competent medical evidence that meaningfully refers to and addresses the insurer's findings. At trial both Appellate Terms use a burden-shifting framework (West Tremont, 2006). In the Second Department Appellate Term, once the insurer rebuts the presumption of medical necessity, the provider bears the ultimate burden of proving necessity by a preponderance (Park Slope v Travelers, 2012; Dayan, 2015; James J. Kim, 2023). Several Second Department trial courts said the insurer bears the burden of persuasion (Nir v Allstate, 2005; CityWide, 2004; Complete Med. Care, 2008; All Boro, 2012; Longevity, 2022). That is a trial-level divergence on the burden of persuasion, not an appellate split.

Leading authorities · Authority map · Decisions by court · Plain-text version (Markdown)

Leading authorities

AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C. (2016 NY Slip Op 00916) Appellate Division, Second Department, 2016Affirmed medical evaluations make the showing; provider's records can rebutThe insurer's affirmed medical evaluations made a prima facie showing that the services were not medically necessary. The provider's affidavits and medical records raised a triable issue of fact, so summary judgment was properly denied.
the plaintiff submitted affirmed medical evaluations which made a prima facie showing [*2]that the services at issue were not medically necessary
A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) Appellate Division, Second Department, 2007Peer-review-based denial raises triable issue against provider's motionThe provider made its prima facie case, but the insurer raised a triable issue on its defense that the benefits were properly denied for lack of medical justification. The denial form need not set out a medical rationale.
in response, the defendant raised a triable issue of fact with respect to its argument that the claimed benefits were properly denied on the ground of lack of medical justification
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U)) Appellate Term, Second Department, 2007Unrebutted peer review entitles insurer to summary judgmentThe insurer's peer review report established prima facie that the MRIs were not medically necessary. Because the provider did not rebut it, the court searched the record and granted the insurer's cross motion.
Defendant’s peer review report established prima facie that there was no medical necessity for the MRIs performed by plaintiff, which evidence was unrebutted, thereby entitling defendant to the relief it sought below
Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) Appellate Term, Second Department, 2009Rebuttal must meaningfully refer to the peer reviewA sworn peer review with a factual basis and medical rationale shifted the burden to the provider. A conclusory affidavit that only disagreed, without meaningfully referring to or discussing the peer review, did not raise a triable issue.
The affidavit submitted by plaintiff in opposition was insufficient as it merely consisted of a conclusory statement by the affiant that he disagreed with the opinion of defendant s peer review doctor that there was no medical necessity for the services rendered. The affiant did not meaningfully refer to, or discuss, the determination of defendant’s doctor.
West Tremont Med. Diagnostic, P.C. v Geico Ins. Co. (2006 NY Slip Op 51871(U)) Appellate Term, Second Department, 2006At trial, insurer's showing shifts burden to providerAt trial, the claim forms raise a presumption of medical necessity. The insurer's unrebutted expert testimony of no medical necessity shifted the burden to the provider. The provider offered no evidence, so judgment was directed for the insurer.
Where the defendant insurer presents sufficient evidence to establish a defense based on the lack of medical necessity, the burden shifts to the plaintiff which must then present its own evidence of medical necessity
Park Slope Med. & Surgical Supply, Inc. v Travelers Ins. Co. (2012 NY Slip Op 22200) Appellate Term, Second Department, 2012Trial: records admissible; provider bears ultimate burdenThe medical records the insurer's peer reviewer relied on are admissible at trial because they are offered only to show what was conveyed to the insurer, not for their truth. Once the insurer meets its burden, the provider must prove medical necessity by a preponderance of the evidence.
Assuming the insurer is successful in satisfying its burden, it is ultimately plaintiff who must prove, by a preponderance of the evidence, that the services or supplies were medically necessary.
Alvarez v Prospect Hosp. 68 NY2d 320Summary-judgment burden shifting applied to the insurer's peer review showing and the provider's rebuttal (cited by about 51 candidates).Not in our database.
Zuckerman v City of New York 49 NY2d 557Opponent must produce evidentiary proof in admissible form to raise a triable issue; cited by about 112 candidates in medical-necessity rulings.Not in our database.
Arnica Acupuncture PC v Interboro Ins. Co. 137 AD3d 421Cited by App Term 1st (TC Acupuncture 2016, Mingmen 2018) for the rule that subjective complaints of pain cannot overcome the objective tests in the insurer's IME report. The text is not in the database.Not in our database.
Insurance Law § 5102 (a) (1); 11 NYCRR 65-1.1 statute/regulationOnly 'necessary expenses' are reimbursable; this is the source of the defense (Long Is. Radiology, 36 AD3d 763).Not in our database.
11 NYCRR 65-3.8 (b) (4) regulationA denial may rest on a peer review or IME report, which must be released on written request (A.B. Med. Servs. v Liberty Mut., 39 AD3d 779).Not in our database.

Authority map

Each circle is a decision on this question, placed by court and date; its colour is the position it took. Lines are citations between them. Select a circle (or find a decision by name) to see its links and summary. The same decisions are listed by court below the map.

Insurer's proof established lack of medical necessity and the provider failed to rebut itProvider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Insurer's proof was enough to defeat the provider's motion but not to winInsurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingRing: rules on the question, but another ground decided the caseContrasted, distinguished or limitedDeclined to follow, questioned, overruled or reversedCited Show ordinary citations

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How the rule was applied, by court

Court	Unrebutted, insurer prevails	Provider's rebuttal sufficient	Insurer raised triable issue	Insurer's proof insufficient	Trial error, new trial	Total
Appellate Division, First Department	0	0	1	0	0	1
Appellate Division, Second Department	0	2	2	5	0	9
Appellate Division, Third Department	0	1	0	0	0	1
Appellate Division, Fourth Department	0	0	1	0	0	1
Appellate Term, First Department	25	7	5	18	5	60
Appellate Term, Second Department	288	85	60	58	25	516
Trial courts in the First Department	3	2	1	4	0	10
Trial courts in the Second Department	27	8	5	44	3	87
Trial courts in the Fourth Department	0	0	0	1	0	1

Decisions (686)

Every decision in our database that rules on this question: highest court first, then by department, newest first. 631 turn on it; the others rule on it alongside a different main ground (marked "also decides"). The one-sentence summaries describe what each court said on this question.

Appellate Division, First Department (1 decision)

Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059) Appellate Division, First Department, April 3, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer raised a triable issue whether the benefits were properly denied for lack of medical justification, noting a nurse's review is not per se invalid, so the provider's summary judgment was vacated.

Appellate Division, Second Department (9 decisions)

Hernandez v Merchants Mut. Ins. Co. (2022 NY Slip Op 04156) Appellate Division, Second Department, June 29, 2022Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's opposition did not include admissible evidence sufficient to raise a triable issue that the spinal disc surgery claims were properly denied for lack of medical justification, so summary judgment for the claimant was affirmed.
Healthplus Surgery Ctr., LLC v American Tr. Ins. Co. (2022 NY Slip Op 02252) Appellate Division, Second Department, April 6, 2022Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports insufficient because each doctor merely gave a conclusory opinion that the injuries were degenerative and chronic and conservative treatment would suffice, without a factual basis and medical rationale.
Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 03772) Appellate Division, Second Department, July 8, 2020Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's peer review, IME report and records made a prima facie showing, but the provider's expert affidavit relying on MRI results and surgical findings raised a triable issue of medical necessity.
Allstate Ins. Co. v Buffalo Neurosurgery Group (2019 NY Slip Op 03749) Appellate Division, Second Department, May 15, 2019Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports failed to demonstrate prima facie that the spinal fusion surgery was not medically necessary, so the opposing papers need not be considered.
Global Liberty Ins. Co. v W. Joseph Gorum, M.D., P.C. (2016 NY Slip Op 06680) Appellate Division, Second Department, October 12, 2016Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports and medical records failed to establish as a matter of law that the surgery was not medically necessary, so summary judgment was denied without considering the opposition.
AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C. (2016 NY Slip Op 00916) Leading case Appellate Division, Second Department, February 10, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's affirmed medical evaluations made a prima facie showing of no medical necessity, but the provider's affidavits and medical records raised a triable issue, so the insurer's declaratory summary judgment motion was properly denied.
Vista Surgical Supplies, Inc. v Travelers Ins. Co. (2008 NY Slip Op 03199) Appellate Division, Second Department, April 8, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports inadmissible because they bore computerized or stamped facsimile signatures without proof of who affixed them or that they were authorized, so they could not defeat the provider's summary judgment motion.
A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) Leading case Appellate Division, Second Department, April 24, 2007Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer raised a triable issue that the benefits were properly denied for lack of medical justification, so the provider's motion was correctly denied.

Show all 9 decisions

A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co. (2007 NY Slip Op 03635) Appellate Division, Second Department, April 24, 2007Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held in the alternative that the insurer raised a triable issue against the provider's motion on its peer-review-based denials, rejecting the view that the denial forms had to state a factual basis and medical rationale.

Appellate Division, Third Department (1 decision)

Wolf v Holyoke Mut. Ins. Co. (2004 NY Slip Op 00075) Appellate Division, Third Department, January 8, 2004Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Weighing the insurer's IME that further treatment, household help and tests were unneeded against the treating physicians' affirmations and a later examining physician's letter, found the continued benefits warranted and the denial improper.

Appellate Division, Fourth Department (1 decision)

Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co. (2009 NY Slip Op 06984) Appellate Division, Fourth Department, October 2, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer raised a triable issue by submitting denial forms stating the services were not medically necessary, and that the defense was available against the radiology assignee after services were rendered.

Appellate Term, First Department (60 decisions)

Jamaica Chiropractic PT PLLC v MVAIC (2024 NY Slip Op 50614(U)) Appellate Term, First Department, May 23, 2024Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because the IME report gave a factual basis and medical rationale that injuries had resolved, and the provider offered only an attorney's affirmation without medical evidence.
Omega 18 Inc. v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 50235(U)) Appellate Term, First Department, February 19, 2020Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established that the whirlpool, heat lamp and massager were unnecessary or redundant given ongoing therapy, and the attorney's affirmation with prescription and claim forms, lacking medical evidence, raised no triable issue.
Forest Drugs v Global Liberty Ins. Co. of N.Y. (2018 NY Slip Op 51708(U)) Appellate Term, First Department, November 29, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME showing resolved injuries established lack of need for further treatment, and the provider's medical affirmation, not based on an examination and not meaningfully rebutting the IME findings, raised no triable issue.
Mingmen Acupuncture Servs., PC v Global Liberty Ins. Co. of N.Y. (2018 NY Slip Op 51358(U)) Appellate Term, First Department, September 26, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report showing resolved injuries and normal range of motion established no need for further acupuncture, and the principal's affidavit, not based on an examination, failed to meaningfully rebut it.
Cappello v Global Liberty Ins. Co. of N.Y. (2017 NY Slip Op 51415(U)) Appellate Term, First Department, October 26, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itDirected judgment for the insurer because its credited peer reviewer's testimony gave a factual basis and medical rationale for finding the EMG/NCV testing unnecessary, and the provider called no rebuttal witnesses.
Palisade Surgery Ctr. LLC v Allstate Prop. & Cas. Ins. Co. (2016 NY Slip Op 51824(U)) Appellate Term, First Department, December 29, 2016Insurer's proof was enough to defeat the provider's motion but not to winUpheld denial of the providers' cross motion on medical necessity because the parties' conflicting medical expert opinions raised a triable issue regarding the manipulation under anesthesia.
TC Acupuncture, P.C. v Tri-State Consumer Ins. Co. (2016 NY Slip Op 50978(U)) Appellate Term, First Department, June 27, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME report set forth a sufficient basis and medical rationale for no further acupuncture, and an attorney's affirmation without medical evidence failed to raise a triable issue, so the later claims were dismissed.
Lotus Acupuncture PC v Unitrin Advantage Ins. Co. (2016 NY Slip Op 50603(U)) Appellate Term, First Department, April 18, 2016Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the acupuncture peer review insufficient because its assertion that the records lacked supportive information made no prima facie showing, and it did not address a later date of service or rule out further treatment.

Show all 60 decisions

Karina K. Acupuncture, P.C. v AIG Centennial Ins. Co. (2016 NY Slip Op 50415(U)) Appellate Term, First Department, March 28, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld summary judgment for the insurer because its IME report gave a factual basis and medical rationale for ending acupuncture, and the provider's attorney's affirmation without medical evidence raised no triable issue.
Five Boro Med. Equip., Inc. v A. Cent. Ins. Co. (2016 NY Slip Op 50412(U)) Appellate Term, First Department, March 28, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held one peer review insufficient because pages were missing, and that the other made a prima facie showing but was answered by the provider's medical affidavit describing the assignor's conditions and the supplies' intended benefits.
Pugsley Chiropractic PLLC v Merchants Preferred Ins. Co. (2016 NY Slip Op 50167(U)) Appellate Term, First Department, February 17, 2016Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the IME report inadmissible because a chiropractor or acupuncturist cannot affirm under CPLR 2106 and the report was not shown to be sworn, so the insurer's motion should have been denied.
Premier Health Choice v Praetorian Ins. Co. (2015 NY Slip Op 51383(U)) Appellate Term, First Department, September 29, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its IME reports showed the injuries had resolved with no need for further therapy, and the provider's unsworn doctor's report had no probative value.
Rummel G. Mendoza, D.C., P.C. v Chubb Indem. Ins. Co. (2015 NY Slip Op 50900(U)) Appellate Term, First Department, June 17, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because the IME reports found the injuries resolved, and the treating therapist's affidavit failed to meaningfully address the examiner's findings, including normal range-of-motion results.
SMB Med., PC v Federal Ins. Co. (2015 NY Slip Op 50895(U)) Appellate Term, First Department, June 12, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer partial summary judgment on the acupuncture claims because the provider's opposition did not address the acupuncturist's IME, while conflicting expert opinions raised a triable issue on the remaining claims.
Pugsley Chiropractic PLLC v MVAIC (2015 NY Slip Op 50718(U)) Appellate Term, First Department, May 13, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn chiropractic IME report showed injuries resolved with a factual basis and medical rationale, and the provider's attorney's affirmation without medical evidence raised no triable issue.
Orthopedic Specialist of Greater NY v Chubb Indem. Ins. Co. (2015 NY Slip Op 50565(U)) Appellate Term, First Department, April 21, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held conflicting medical expert opinions raised a triable issue as to the medical necessity of the orthopedic surgery, so the insurer's motion was properly denied on the $3,408.11 claim.
V.S. Care Acupuncture PC v MVAIC (2015 NY Slip Op 50350(U)) Appellate Term, First Department, March 23, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn IME report gave a factual basis and medical rationale that injuries had resolved, and the provider offered only an attorney's affirmation without medical evidence.
Five Boro Med. Equip., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51888(U)) Appellate Term, First Department, December 31, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set out a sufficient factual basis and medical rationale, and the provider's attorney affirmation without medical evidence raised no triable issue; objections to the reviewer's qualifications went to weight.
Cortland Med. Supply, Inc. v 21st Century Centennial Ins. Co. (2014 NY Slip Op 51886(U)) Appellate Term, First Department, December 31, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because the peer review set forth a factual basis and medical rationale and the provider offered only an attorney's affirmation without medical evidence.
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U)) Appellate Term, First Department, December 17, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the peer review acupuncturist's report lacked sufficient facts or medical rationale, as the assignor's subjective report of feeling worse did not without objective explanation eliminate triable issues on continued treatment.
NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U)) Appellate Term, First Department, November 3, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer raised no triable issue because, despite a timely denial, it failed to submit the IME report underlying the denial or any other evidence supporting its medical-necessity defense.
Shirom Acupuncture, P.C. v Kemper Independence Ins. Co. (2014 NY Slip Op 51407(U)) Appellate Term, First Department, September 22, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review insufficient because it addressed an earlier treatment period, rested on narrow documentation grounds, and did not conclude further acupuncture could never be warranted.
Arnica Acupuncture P.C. v Interboro Ins. Co. (2014 NY Slip Op 50554(U)) Appellate Term, First Department, April 9, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that conflicting medical expert opinions on the necessity of the acupuncture raised a triable issue, so neither side was entitled to summary judgment and the provider's award on a search of the record was vacated.
Webster Ave Med. Pavilion, PC v Allstate Ins. Co. (2014 NY Slip Op 50393(U)) Appellate Term, First Department, March 19, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed its burden at trial because the court could reject its expert's sparse, confusing testimony, which admitted ignorance of the assignor's condition at testing, even though it was unopposed.
Drew De Marco, P.C. v Allstate Ins. Co. (2013 NY Slip Op 52212(U)) Appellate Term, First Department, December 24, 2013Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld that the insurer's stipulated chiropractic expert need not be certified in manipulation under anesthesia to opine on its medical necessity, since lack of certification goes to weight, and ordered a new trial.
Pomona Med. Diagnostics, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 52131(U)) Appellate Term, First Department, December 13, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because the parties' conflicting medical expert opinions raised a triable issue as to the medical necessity of the diagnostic tests.
Premier Health Choice Chiropractic, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 51802(U)) Appellate Term, First Department, October 30, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on a sworn IME report showing resolved injuries; the provider's unsworn doctor's report lacked probative value and in any event did not meaningfully refer to or rebut the insurer's findings.
Amherst Med. Supply, LLC v A. Cent. Ins. Co. (2013 NY Slip Op 51800(U)) Appellate Term, First Department, October 30, 2013Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Affirmed denial of the insurer's motion because the peer reviewer's bald assertion that supplies were unneeded lacked a factual basis and medical rationale; the treating chiropractor's affidavit would in any event raise a triable issue.
Hunt City Chiropractic, LLP v Chubb Indem. Ins. Co. (2013 NY Slip Op 51679(U)) Appellate Term, First Department, October 15, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because the parties' conflicting medical expert opinions raised a triable issue as to the medical necessity of the chiropractic services.
AP Diagnostic Med., PC v Chubb Indem. Ins. Co. (2013 NY Slip Op 51647(U)) Appellate Term, First Department, October 7, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Although the insurer made a prima facie showing that the MRI was unnecessary, the provider's medical affidavit detailing complaints and restricted range of motion and explaining the MRI's purpose raised a triable issue, so summary judgment was denied.
Queens Integrated Med. Care P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 51400(U)) Appellate Term, First Department, August 23, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because the parties' conflicting medical expert opinions raised a triable issue as to the medical necessity of the physical therapy and related services.
Synergy Med. v Praetorian Ins. Co. (2013 NY Slip Op 51047(U)) Appellate Term, First Department, July 2, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review gave a factual basis and medical rationale against the MUA procedures, while the provider's unsworn, conclusory operative reports failed to raise a triable issue.
Utica Acupuncture, P.C. v Interboro Ins. Co. (2013 NY Slip Op 50643(U)) Appellate Term, First Department, April 18, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's IME report showing resolved injuries established lack of necessity for later acupuncture, and the provider's principal's general affidavit on Chinese medicine, saying nothing of the assignor's injuries, raised no triable issue.
Amherst Med. Supply, LLC v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50586(U)) Appellate Term, First Department, April 16, 2013Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Denied the insurer summary judgment because its chiropractor's peer review lacked a factual basis and medical rationale, baldly asserting the file lacked supportive information without identifying missing records.
Innovative MR Imaging, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50264(U)) Appellate Term, First Department, February 21, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn chiropractic peer review set forth a factual basis and rationale against the MRIs, and the provider's unsworn, conclusory treating chiropractor letter raised no triable issue.
Hillside Surgicare Diagnostic & Treatment Ctr., LLC v Utica Mut. Ins. Co. (2012 NY Slip Op 51371(U)) Appellate Term, First Department, July 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itDismissed the complaint because the orthopedist's peer review detailed a factual basis and rationale against the shoulder arthroscopy, and the provider offered only an attorney's affirmation with unsworn, inadmissible medical reports.
Ashraf Ashour Physical Therapy, P.C. v Interboro Mut. Indem. Ins. Co. (2012 NY Slip Op 50491(U)) Appellate Term, First Department, March 20, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Held the provider failed to rebut the insurer's IME report for one claim, so summary judgment dismissing that claim was granted on renewal.
Darlington Med. Diagnostics, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 50226(U)) Appellate Term, First Department, February 16, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because the sworn chiropractic peer review was sufficient and the provider's affidavit was generic, unfounded and did not address the review, while its unsigned report could not be considered.
Diagnostic Medicine, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 50102(U)) Appellate Term, First Department, January 25, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review showed the diagnostic testing lacked medical necessity, and the provider's attorney's affirmation, unaccompanied by medical evidence, raised no triable issue, so the complaint was dismissed.
Triangle R Inc. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51663(U)) Appellate Term, First Department, September 9, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's submissions established prima facie lack of medical necessity of the supplies, and the provider's undated, unsworn medical report could not be considered and in any event was insufficient to raise a triable issue.
Devonshire Surgical Facility v American Tr. Ins. Co. (2011 NY Slip Op 50513(U)) Appellate Term, First Department, April 5, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Granted the providers summary judgment because the insurer's peer review report was conclusory and did not set forth sufficient facts to raise a triable issue on lack of medical necessity.
Enko Enters. Intl., Inc. v Clarendon Natl. Ins. Co. (2010 NY Slip Op52267(U)) Appellate Term, First Department, December 30, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the physician's affirmed peer review, opining the supplies were unnecessary because the assignor already received physical and chiropractic therapy, established lack of medical necessity, and the provider submitted no evidence raising a triable issue.
Globe Med. Care O.L.P.C. v Travelers Ins. Co. (2010 NY Slip Op 50020(U)) Appellate Term, First Department, January 11, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Directed judgment for the provider because the insurer adduced no evidence at trial on medical necessity, its only defense.
Bronx Expert Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 51475(U)) Appellate Term, First Department, July 13, 2009Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingReversed a directed verdict for the provider, holding the insurer's expert should have been allowed to testify within the peer review's basis even if relying on records of the provider and other physicians, and remanded.
Krishna v Liberty Mut. Ins. Co. (2009 NY Slip Op 51312(U)) Appellate Term, First Department, June 29, 2009Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the peer review report, as amplified after additional documentation was received, set forth sufficient facts to raise a triable issue on medical necessity, so the provider's summary judgment motion was properly denied.
A Plus Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50824(U)) Appellate Term, First Department, April 29, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer was not entitled to summary judgment because its submissions did not conclusively establish its lack of medical necessity defense as a matter of law.
Mollins v State Farm Gen. Ins. Co. (2009 NY Slip Op 50763(U)) Appellate Term, First Department, April 22, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to raise a triable issue because the chiropractor's report supporting its lack of medical necessity defense was unsworn and therefore not in admissible form.
OS Tigris Acupuncture, P.C. v Liberty Mut. Insurance Co. (2008 NY Slip Op 51996(U)) Appellate Term, First Department, October 7, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn chiropractor's IME report inadmissible and, in any event, insufficient to raise an issue because it concluded only that further acupuncture was unnecessary, not the treatment at issue.
Bronx Multi Med. Care, P.C. v Kemper Cas. Ins. Co. (2008 NY Slip Op 51928(U)) Appellate Term, First Department, September 24, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer raised no triable issue on medical necessity because its peer review report was unsigned, did not comply with CPLR 2106, and so was not admissible evidence.
Mollins v Allstate Ins. Co. (2008 NY Slip Op 51616(U)) Appellate Term, First Department, July 28, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to raise a triable issue on lack of medical necessity because it did not submit the IME report on which its denials were based or any other evidentiary proof.
CPT Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 27526) Appellate Term, First Department, December 19, 2007Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer reviewer's affidavit established lack of necessity for the diagnostic testing, and the provider's attorney affirmation with an unsworn doctor's report was inadmissible and, in any event, failed to address a prior negative study.
Spruce Med. & Diagnostic, P.C. v Lumbermen's Mut. Cas. Co. (2007 NY Slip Op 51104(U)) Appellate Term, First Department, May 30, 2007Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingReversed and remanded for a new trial because the insurer's expert should not have been precluded merely for not authoring the peer review, since he was subject to cross-examination and limited to the report's stated basis.
A.I.D. Med. Supplies v GEICO Gen. Ins. Co. (2007 NY Slip Op 51044(U)) Appellate Term, First Department, May 23, 2007Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer raised a triable issue defeating the provider's summary judgment motion by showing it timely denied the claim for lack of medical necessity based on a peer review report, the denial form needing no medical rationale.
Home Care Ortho. Med. Supply, Inc. v American Manufactures Mut. Ins. Co. (2007 NY Slip Op 50302(U)) Appellate Term, First Department, February 26, 2007Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld it was error to preclude the insurer's expert for not having written the peer review or for relying on the assignors' medical records the provider itself submitted, and remanded for trial.
East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50213(U)) Appellate Term, First Department, February 8, 2007Insurer'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.
Mollins v Motor Veh. Acc. Indem. Corp. (2007 NY Slip Op 50138(U)) Appellate Term, First Department, January 30, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn chiropractor's report on lack of medical necessity was not in admissible form under CPLR 2106 and had to be excluded, so no triable issue was raised.
Response Med. Equip. v General Assur. Co. (2006 NY Slip Op 51765(U)) Appellate Term, First Department, September 20, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's detailed peer reviews in admissible form raised triable issues defeating the provider's motion on two assignors' claims, while for another claim the insurer failed to produce the peer review or other competent proof.
Cross Cont. Med., P.C. v Allstate Ins. Co. (2006 NY Slip Op 26322) Appellate Term, First Department, August 15, 2006Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the insurer's expert could testify from the provider's own records because the provider could not attack their reliability, so precluding his testimony and directing judgment for the provider was error requiring a new trial.
Vladimir Zlatnick, M.D., P.C. v Travelers Indem. Co. (2006 NY Slip Op 50963(U)) Appellate Term, First Department, May 22, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Affirmed judgment for the provider after trial because the insurer's peer review report was conclusory and lacked a detailed basis and medical rationale, and the provider's credited neurological expert supported medical necessity.
A.b. Med. Servs. Pllc v Cna Ins. Co. (2004 NY Slip Op 50061(U)) Appellate Term, First Department, February 11, 2004Insurer's proof was enough to defeat the provider's motion but not to winDenied the provider summary judgment on the timely denied claims because the insurer's peer review reports were a proper basis for the defense and set forth sufficient facts to raise a triable issue of medical necessity.

Appellate Term, Second Department (516 decisions)

James J. Kim, L.A.C., P.C. v Allstate Ins. Co. (2023 NY Slip Op 50587(U)) Appellate Term, Second Department, May 26, 2023Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed judgment after trial for the provider because, crediting its expert over the insurer's, the record supported the finding that the provider proved medical necessity by a preponderance of the evidence.
UGP Acupuncture, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50610(U)) Appellate Term, Second Department, June 17, 2022Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the provider's opposing affidavit failed to raise a triable issue because it did not meaningfully refer to, let alone rebut, the insurer's prima facie showing of lack of medical necessity for services from August 10, 2016.
Quality Rehab & P.T., P.C. v Tri State Consumers Ins. Co. (2021 NY Slip Op 50730(U)) Appellate Term, Second Department, July 23, 2021Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Held the provider raised no triable issue in opposition to the insurer's showing that the services in two causes of action lacked medical necessity.
Parisien v Tri State Consumers Ins. Co. (2021 NY Slip Op 50728(U)) Appellate Term, Second Department, July 23, 2021Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed IME report, setting forth a factual basis and medical rationale for no further treatment, made a prima facie showing the provider did not rebut, entitling the insurer to summary judgment.
Sufficient Chiropractic Care, P.C. v Global Liberty Ins. Co. (2021 NY Slip Op 50879(U)) Appellate Term, Second Department, May 28, 2021Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the provider's opposing affidavit insufficient to rebut the insurer's prima facie showing of lack of medical necessity, so summary judgment dismissing the complaint was affirmed.
Longevity Med. Supply, Inc. v MVAIC (2021 NY Slip Op 50440(U)) Appellate Term, Second Department, May 14, 2021Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Rejected the provider's sole argument that the insurer had to annex the medical records reviewed by its peer reviewer, leaving dismissal of the first cause of action intact.
Mollo Chiropractic, PLLC v American Commerce Ins. Co. (2020 NY Slip Op 51548(U)) Appellate Term, Second Department, December 23, 2020Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's expert gave a factual basis and medical rationale for finding the MUA procedures unnecessary, stayed within his peer review, and was properly credited over the provider's less credible witness.
Advanced Recovery Equip. & Supplies, LLC v Global Liberty Ins. Co. (2020 NY Slip Op 51373(U)) Appellate Term, Second Department, November 13, 2020Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Affirmed denial of the insurer's summary judgment motion because triable issues of fact existed as to whether the supplies were medically necessary.

Show all 516 decisions

Master Cheng Acupuncture, P.C. v Global Liberty Ins. of N.Y. (2020 NY Slip Op 51371(U)) Appellate Term, Second Department, November 13, 2020Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Agreed that a triable issue of fact existed regarding the medical necessity of the May 23, 2014 services, so the insurer's summary judgment motion was properly denied as to that claim.
First Care Med. Equip., LLC v Kemper Ins. Co. (2020 NY Slip Op 51326(U)) Appellate Term, Second Department, November 6, 2020Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held, as an alternative ground, that the insurer's opposition raised a triable issue as to whether the supplies were medically necessary, so the provider's motion should have been denied.
Sunrise Acupuncture, P.C. v Merchants Preferred Ins. Co. (2019 NY Slip Op 52034(U)) Appellate Term, Second Department, December 13, 2019Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer not entitled to summary judgment on the claims denied for lack of medical necessity because its IME report was not in admissible form, an objection the provider raised below.
Sovera Med. Supply Corp. v 21st Century Ins. Co. (2019 NY Slip Op 51802(U)) Appellate Term, Second Department, November 1, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review set forth a factual basis and medical rationale for lack of necessity of the supplies, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
Quality Comprehensive Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 51734(U)) Appellate Term, Second Department, October 25, 2019Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to establish that the services lacked medical necessity, so dismissal on that ground was reversed.
Merrick Med., P.C. v A Cent. Ins. Co. (2019 NY Slip Op 51264(U)) Appellate Term, Second Department, August 2, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review and IME reports set forth a factual basis and medical rationale for lack of medical necessity, and the provider did not rebut that showing.
Parkway Hosp., Inc. v Integon Natl. Ins. Co. (2019 NY Slip Op 51187(U)) Appellate Term, Second Department, July 19, 2019Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Upheld the trial finding that the insurer failed to rebut the presumption of medical necessity because its expert, who adopted another doctor's peer review, was found not credible, even though the provider called no witnesses.
Active Care Med. Supply Corp. v Erie Ins. Co. of N.Y. (2019 NY Slip Op 51185(U)) Appellate Term, Second Department, July 19, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review set out a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
Quality Custom Med. Supply, Inc. v American Country Ins. Co. (2019 NY Slip Op 51165(U)) Appellate Term, Second Department, July 12, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its peer review set forth a factual basis and medical rationale for lack of medical necessity and the provider submitted no medical evidence in rebuttal.
Jcc Med., P.C. v Hereford Ins. Co. (2019 NY Slip Op 51100(U)) Appellate Term, Second Department, June 28, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld dismissal after trial because the insurer's peer review doctor's testimony rebutted the presumption of medical necessity and the provider, calling no witnesses, failed to prove necessity by a preponderance of the evidence.
Main St. Medcare, P.C. v GEICO Gen. Ins. Co. (2019 NY Slip Op 50686(U)) Appellate Term, Second Department, May 3, 2019Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the trial court erred in precluding, as hearsay, the insurer's expert who had not prepared the peer review report and then directing a verdict for the provider.
Complete Chiropractic, P.C. v GEICO Gen. Ins. Co. (2019 NY Slip Op 50684(U)) Appellate Term, Second Department, May 3, 2019Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the trial court erred in precluding, as hearsay, the insurer's expert who had not prepared the peer review report and then directing a verdict for the provider.
North Am. Partners In Anesthesia, LLP v GEICO Gen. Ins. Co. (2019 NY Slip Op 50683(U)) Appellate Term, Second Department, May 3, 2019Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's non-author expert should have been allowed to testify on lack of medical necessity, limited to the peer review's basis, with the provider bearing the burden to object to testimony beyond it.
Tyorkin v Park Ins. Co. (2019 NY Slip Op 50682(U)) Appellate Term, Second Department, May 3, 2019Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's cross motion properly denied because its papers failed to establish lack of medical necessity as a matter of law.
Success Rehab P.T., P.C. v NY Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 50572(U)) Appellate Term, Second Department, April 12, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed IME report gave a factual basis and medical rationale for finding the injuries resolved and further services unnecessary, and the provider offered no rebuttal.
Advanced Orthopedics, PLLC v GEICO (2019 NY Slip Op 50500(U)) Appellate Term, Second Department, March 29, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal after trial because the trial court credited the insurer's expert that the knee surgery was not medically necessary, being causally unrelated, over the provider's rebutting expert.
Mag Med., P.C. v Kemper Ins. Co. (2019 NY Slip Op 51051(U)) Appellate Term, Second Department, March 1, 2019Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity and the provider submitted no medical evidence in rebuttal.
First Am. Alliance, Inc. v Ameriprise Ins. Co. (2018 NY Slip Op 51765(U)) Appellate Term, Second Department, November 30, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on the $630 bill because its affirmed orthopedic peer review set forth a factual basis and medical rationale for finding the equipment unnecessary and the provider did not rebut it.
Nova Chiropractic Servs., P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 51688(U)) Appellate Term, Second Department, November 23, 2018Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's expert, though not the peer review author, should have been permitted to testify on lack of medical necessity within the basis of the peer review denial.
Nova Chiropractic Servs., P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 51687(U)) Appellate Term, Second Department, November 23, 2018Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingReversed a judgment entered on a directed verdict after the trial court precluded the insurer's medical-necessity expert, remitting for a new trial for the reasons stated in a companion decision.
Nova Chiropractic Servs., P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 51685(U)) Appellate Term, Second Department, November 23, 2018Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingReversed the directed verdict for the provider, entered after the trial court precluded the insurer's medical-necessity expert, and ordered a new trial for the reasons stated in a companion decision.
Gentlecare Ambulatory Anesthesia Servs. v GEICO Ins. Co. (2018 NY Slip Op 51588(U)) Appellate Term, Second Department, November 9, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld summary judgment for the insurer because its sworn peer review gave a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
Active Care Med. Supply Corp. v American Tr. Ins. Co. (2018 NY Slip Op 51584(U)) Appellate Term, Second Department, November 9, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed pre-claim IME report set forth a factual basis and medical rationale for no further supplies, and the provider's affidavit failed to meaningfully refer to or rebut it.
Essential Acupuncture Servs., P.C. v GEICO Indem. Co. (2018 NY Slip Op 51600(U)) Appellate Term, Second Department, November 9, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME acupuncturist's sworn report, finding the injuries resolved with a factual basis and medical rationale, established lack of medical necessity, and the provider did not rebut it, so those claims were dismissed.
Bay Plaza Chiropractic, P.C. v Auto One Ins. Co. (2018 NY Slip Op 51082(U)) Appellate Term, Second Department, July 6, 2018Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because a triable issue of fact existed regarding the medical necessity of the services.
Parkway Med. Care, P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 51005(U)) Appellate Term, Second Department, June 22, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld summary judgment for the insurer because its affirmed neurologist's peer review set forth a factual basis and medical rationale for lack of medical necessity and the provider did not rebut it.
Precious Acupuncture Care, P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 50827(U)) Appellate Term, Second Department, June 1, 2018Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's cross motion on one cause of action because a triable issue of fact existed regarding the medical necessity of the services.
County Line Pharmacy v Geico Ins. Co. (2018 NY Slip Op 50574(U)) Appellate Term, Second Department, April 13, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itReversed the Civil Court's finding of a triable issue on medical necessity and granted the insurer summary judgment dismissing the supply claims, for the reasons stated in a companion decision decided the same day.
County Line Pharmacy v Geico Ins. Co. (2018 NY Slip Op 50573(U)) Appellate Term, Second Department, April 13, 2018Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale that injuries had resolved and the prescription drugs were unnecessary, and the provider, which did not oppose, failed to rebut it.
Trimed Med. Supply, Inc. v GEICO Ins. Co. (2017 NY Slip Op 51957(U)) Appellate Term, Second Department, December 29, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's expert who did not author the peer review should have been allowed to testify on lack of medical necessity, limited to the peer review's basis for denial.
Excel Surgery Ctr., L.L.C. v Hertz Claim Mgt. Corp. (2017 NY Slip Op 51951(U)) Appellate Term, Second Department, December 28, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Denied the insurer summary judgment because the treating chiropractor's affidavit meaningfully referred to and rebutted the insurer's sworn peer review, raising a triable issue of fact.
Staten Is. Advanced Surgical Supply v GEICO Ins. Co. (2017 NY Slip Op 51895(U)) Appellate Term, Second Department, December 22, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's non-author expert should have testified even though the unauthenticated peer review was not admitted, since the provider's objection sufficed if testimony exceeded the report's scope.
Greater NY Med. Care, P.C. v Allstate Ins. Co. (2017 NY Slip Op 51849(U)) Appellate Term, Second Department, December 22, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the trial court found the insurer's credible expert proved lack of medical necessity unrebutted yet awarded judgment to the provider, a contradiction requiring retrial.
W.H.O. Acupuncture, P.C. v GEICO Indem. Co. (2017 NY Slip Op 51900(U)) Appellate Term, Second Department, December 22, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the acupuncturist's sworn IME report set forth a factual basis and medical rationale for lack of necessity of further treatment, and the provider did not rebut it, so the insurer got summary judgment.
Jamaica Med. Plaza, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51837(U)) Appellate Term, Second Department, December 19, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's expert who did not prepare the peer review should have been permitted to testify on lack of medical necessity, limited to the peer review's basis for denial.
Comprehensive Psychological Servs. of NY, P.C. v GEICO Ins. Co. (2017 NY Slip Op 51815(U)) Appellate Term, Second Department, December 19, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld dismissal after trial because the credited insurer expert showed the services were not medically necessary, shifting the burden to the provider, which submitted no evidence to prove necessity by a preponderance.
Khan v New York Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51812(U)) Appellate Term, Second Department, December 19, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because a triable issue of fact existed regarding the medical necessity of the services.
Kensington Radiology Group, P.C. v National Am. Ins. Co. (2017 NY Slip Op 51811(U)) Appellate Term, Second Department, December 19, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because the record presented a triable issue of fact regarding the medical necessity of the services.
Jamaica Dedicated Med. Care, P.C. v Tri State Consumer Ins. Co. (2017 NY Slip Op 51790(U)) Appellate Term, Second Department, December 19, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Agreed that a triable issue of fact existed regarding medical necessity for the claims denied on that ground, so the insurer's cross motion was properly denied.
Radiology Today, P.C. v Geico Ins. Co. (2017 NY Slip Op 51768(U)) Appellate Term, Second Department, December 15, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the trial court wrongly directed a verdict on the view that the insurer could not meet its burden without admitting the peer review for its truth; a substitute expert may testify, limited to the denial's basis.
Elena Ocher Med., P.C. v Infinity Ins. Co. (2017 NY Slip Op 51730(U)) Appellate Term, Second Department, December 8, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion for summary judgment based on lack of medical necessity because a triable issue of fact existed regarding the medical necessity of the services.
Atlantic Chiropractic, P.C. v Geico Ins. Co. (2017 NY Slip Op 51253(U)) Appellate Term, Second Department, September 22, 2017Insurer's proof was enough to defeat the provider's motion but not to winReversed the provider's summary judgment because the insurer's opposing proof raised a triable issue as to the medical necessity of the services.
XVV, Inc. v Farmington Cas. Co. (2017 NY Slip Op 51231(U)) Appellate Term, Second Department, September 22, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Denied the insurer summary judgment because, although its peer review set forth a factual basis and medical rationale, the provider's medical affidavit raised a triable issue as to medical necessity.
Promed Orthocare Supply, Inc. v Geico Ins. Co. (2017 NY Slip Op 51264(U)) Appellate Term, Second Department, August 4, 2017Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial on the traction unit claim because the trial court wrongly disregarded testimony from an expert who had not written the peer review; the provider bore the burden to object to testimony beyond the denial's basis.
Jaga Med. Servs., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50954(U)) Appellate Term, Second Department, July 21, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's sworn peer review set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut it, so those causes of action were dismissed.
Orlin & Cohen Orthopedic Assoc. v Allstate Ins. Co. (2017 NY Slip Op 50937(U)) Appellate Term, Second Department, July 21, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld dismissal of the spinal surgery claim because the credited peer reviewer's testimony that the surgery was not medically necessary, being unrelated to the accident, rebutted the presumption and the provider called no witnesses.
Gentle Acupuncture, P.C. v Tri-State Consumer Ins. Co. (2017 NY Slip Op 50706(U)) Appellate Term, Second Department, May 23, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's sworn IME report made a prima facie showing, but the treating acupuncturist's affirmation meaningfully referred to and sufficiently rebutted it, with jurat and CPLR 2106 objections not fatal or waived.
Acuhealth Acupuncture, P.C. v Ameriprise Ins. Co. (2017 NY Slip Op 50119(U)) Appellate Term, Second Department, January 20, 2017Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's expert's sworn IME report established prima facie a lack of medical necessity for the later services, and the provider failed to raise a triable issue.
Metropolitan Diagnostic Med. Care, P.C. v Erie Ins. Co. of N.Y. (2016 NY Slip Op 51815(U)) Appellate Term, Second Department, December 16, 2016Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Upheld judgment for the provider because the trial court found the insurer's peer reviewer not credible, although his specialty went only to the weight of his testimony, not his competence to testify.
New Capital Supply, Inc. v Chubb Ins. Co. (2016 NY Slip Op 51677(U)) Appellate Term, Second Department, November 15, 2016Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held neither peer review report set forth a factual basis or medical rationale showing the supplies were unnecessary, so the insurer was not entitled to summary judgment on any claim.
North Bronx Med. Health Care v Auto One Ins. Co. (2016 NY Slip Op 51625(U)) Appellate Term, Second Department, November 1, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Upheld denial of the insurer's summary judgment motion because a triable issue of fact existed as to the medical necessity of both claims.
Al Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51515(U)) Appellate Term, Second Department, October 13, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn IME report set out a factual basis and medical rationale for lack of medical necessity, and the provider did not oppose the cross motion.
Quality Health Prods., Inc v Geico Gen. Ins. Co. (2016 NY Slip Op 51430(U)) Appellate Term, Second Department, September 27, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Upheld denial of the insurer's cross motion based on lack of medical necessity because a triable issue of fact existed regarding the medical necessity of the supplies.
Theracare & Wellness, P.T., P.C. v Great N. Ins. Co. (2016 NY Slip Op 51429(U)) Appellate Term, Second Department, September 27, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because an affirmed pre-treatment IME report gave a factual basis and medical rationale for finding further treatment unnecessary, and the provider did not rebut it.
Metro Psychological Servs., P.C. v Auto One Ins. Co. (2016 NY Slip Op 51376(U)) Appellate Term, Second Department, September 21, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Upheld denial of the insurer's summary judgment motion because a triable issue of fact existed regarding the medical necessity of the services.
Arguelles, M.D., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51366(U)) Appellate Term, Second Department, September 19, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's prima facie showing that the services were not medically necessary stood because the provider submitted no admissible medical proof in rebuttal.
Dr. Ronda M. Bachenheimer/Meadowbrook Chiropractic v Allstate Ins. Co. (2016 NY Slip Op 51324(U)) Appellate Term, Second Department, September 15, 2016Insurer's proof was enough to defeat the provider's motion but not to winUpheld denial of the provider's summary judgment motion because a triable issue of fact existed regarding the medical necessity of the services.
DAC Medical, P.C./Timothy Mosomillo, D.O. v Allstate Ins. Co. (2016 NY Slip Op 51322(U)) Appellate Term, Second Department, September 15, 2016Insurer's proof was enough to defeat the provider's motion but not to winUpheld denial of the provider's summary judgment motion because a triable issue of fact existed regarding the medical necessity of the services.
Al Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51245(U)) Appellate Term, Second Department, August 18, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report set forth a factual basis and medical rationale, and the provider's affidavit failed to meaningfully refer to or rebut it, so the insurer got summary judgment on those claims.
Mathews v Allstate Ins. (2016 NY Slip Op 51174(U)) Appellate Term, Second Department, July 28, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld dismissal after trial because the trial court accepted the insurer's expert testimony of no medical necessity; his non-orthopedic specialty went to weight only, and the provider did not prove necessity by a preponderance.
New Horizon Surgical Ctr., L.L.C. v Allstate Ins. Co. (2016 NY Slip Op 51125(U)) Appellate Term, Second Department, July 13, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itDirected judgment for the insurer because its credited chiropractor expert, whose expertise was stipulated, gave a factual basis and medical rationale for finding the MUA unnecessary, and the provider called no rebuttal witnesses.
New Horizon Surgical Ctr., L.L.C. v Allstate Ins. Co. (2016 NY Slip Op 51124(U)) Appellate Term, Second Department, July 13, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itDirected judgment for the insurer because its credited IME chiropractor showed the assignor's injuries had resolved, making the MUA unnecessary, and the provider presented no evidence that the condition changed or the opinion was wrong.
DJS Med. Supplies, Inc. v Allstate Ins. Co. (2016 NY Slip Op 51123(U)) Appellate Term, Second Department, July 13, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld the trial finding that the supplies other than the massager were unnecessary because the trial court credited the insurer's expert and the provider called no rebuttal witness.
Throgs Neck Multicare, P.C. v Mercury Cas. Co. (2016 NY Slip Op 51081(U)) Appellate Term, Second Department, July 8, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Denied the insurer summary judgment because the treating doctor's affirmation, not shown inadmissible under CPLR 2106, meaningfully referred to and rebutted the IME report, creating a triable issue.
Infinite Ortho Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50918(U)) Appellate Term, Second Department, June 6, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its affirmed peer review gave a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
Kanter v Mercury Cas. Co. (2016 NY Slip Op 50908(U)) Appellate Term, Second Department, June 6, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Upheld denial of the insurer's summary judgment motion because the parties' conflicting medical expert opinions raised a triable issue of fact as to medical necessity.
Raymond Cecora, P.T., P.C. v Mercury Cas. Co. (2016 NY Slip Op 50930(U)) Appellate Term, Second Department, June 6, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed IME report set forth a factual basis and medical rationale and the provider's affidavit failed to meaningfully refer to or rebut it.
Ji Sung Kim Acupuncture, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50873(U)) Appellate Term, Second Department, June 3, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on most claims because its affirmed IME report showed further treatment unnecessary, and the treating owner's affidavit failed to meaningfully refer to or rebut the report.
Provek Plus, Inc. v Tri-State Consumer Ins. Co. (2016 NY Slip Op 50870(U)) Appellate Term, Second Department, June 3, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review set forth a factual basis and medical rationale for finding the supplies unnecessary and the provider offered no rebuttal.
Ther-Ox Home Care, Inc. v Praetorian Ins. Co. (2016 NY Slip Op 50869(U)) Appellate Term, Second Department, June 3, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its sworn peer review set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50862(U)) Appellate Term, Second Department, June 3, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Held the provider owner's affidavits opposing the insurer's alternative medical-necessity branch sufficed to demonstrate triable issues of fact, so summary judgment on those two claims was denied.
Raymond Semente, D.C., P.C. v Mercury Cas. Co. (2016 NY Slip Op 50861(U)) Appellate Term, Second Department, June 3, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because the IME chiropractor's sworn statement made a prima facie showing of no further need for treatment and the provider's affidavit failed to meaningfully refer to or rebut it.
Friedman v Allstate Ins. Co. (2016 NY Slip Op 50390(U)) Appellate Term, Second Department, March 18, 2016Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that after the insurer's IME doctor testified the injuries had resolved, the treating acupuncturist's testimony that injuries persisted proved by a preponderance that the post-IME acupuncture was medically necessary, so judgment for the provider was affirmed.
Alleviation Med. Servs., P.C. v Truck Ins. Exch. (2016 NY Slip Op 50382(U)) Appellate Term, Second Department, March 17, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld summary judgment for the insurer because its affirmed peer review gave a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
Rosenzweig v Mercury Cas. Co. (2016 NY Slip Op 50324(U)) Appellate Term, Second Department, March 15, 2016Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review set forth a factual basis and medical rationale and the provider's affidavit failed to meaningfully refer to or rebut it.
J.C. Healing Touch Rehab, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50033(U)) Appellate Term, Second Department, January 8, 2016Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Noted that even had the provider made a prima facie case on one cause of action, conflicting medical expert opinions raised a triable issue of medical necessity defeating its motion.
Huntington Regional Chiropractic, P.C. v Mercury Cas. Co. (2015 NY Slip Op 51900(U)) Appellate Term, Second Department, December 18, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that although the sworn IME report set forth a factual basis and medical rationale, the provider's chiropractor's affidavit raised a triable issue of fact on medical necessity, so summary judgment was properly denied.
Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51756(U)) Appellate Term, Second Department, November 30, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal of the claims denied for lack of medical necessity because the provider's doctor's affirmation failed to meaningfully refer to or rebut the affirmed IME report's conclusions.
Dayan v Allstate Ins. Co. (2015 NY Slip Op 51751(U)) Appellate Term, Second Department, November 30, 2015Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the trial court erred in placing the ultimate burden on the insurer; once the insurer meets its burden showing lack of necessity, including no causal relation to the accident, the provider must prove necessity by a preponderance, so a new trial was ordered.
New Quality Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51697(U)) Appellate Term, Second Department, November 19, 2015Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held triable issues of fact on medical necessity existed for two causes of action, leaving that defense for trial rather than awarding judgment to either side.
Duke Acupuncture, P.C. v Mercury Cas. Co. (2015 NY Slip Op 51701(U)) Appellate Term, Second Department, November 19, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the parties' conflicting medical expert opinions raised a triable issue of fact on medical necessity, so the insurer's summary judgment motion was properly denied.
Ap Orthopedic & Rehabilitation, P.C. v Allstate Ins. Co. (2015 NY Slip Op 51656(U)) Appellate Term, Second Department, November 12, 2015Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Affirmed judgment for the provider after a nonjury trial because, deferring to the trial court's assessment of the insurer's expert's credibility, the insurer failed to demonstrate that the services were not medically necessary.
SAL Med., P.C. v Clarendon Natl. Ins. Co. (2015 NY Slip Op 51449(U)) Appellate Term, Second Department, September 30, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed IME and peer review reports set forth a factual basis and medical rationale, an unsigned report being cured in reply, and the provider offered no rebuttal.
Innovative MR Imaging, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51402(U)) Appellate Term, Second Department, September 16, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review set forth a factual basis and medical rationale and the provider's unsworn, unsigned letters of medical necessity had no probative value.
EMA Acupuncture, P.C. v Geico Ins. Co. (2015 NY Slip Op 51400(U)) Appellate Term, Second Department, September 16, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because the IME reports set forth a factual basis and medical rationale and the provider's acupuncturist's affidavit failed to meaningfully refer to or rebut them.
North Bronx Med. Health Care v Praetorian Ins. Co. (2015 NY Slip Op 51231(U)) Appellate Term, Second Department, August 5, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's summary judgment motion because the record presented triable issues of fact on its lack of medical necessity defense.
Lynbrook Med. of NY, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51226(U)) Appellate Term, Second Department, August 5, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review set forth a factual basis and medical rationale and the provider submitted no medical evidence in rebuttal.
Huntington Regional Chiropractic, P.C. v Truck Ins. Exch. (2015 NY Slip Op 51068(U)) Appellate Term, Second Department, July 13, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that the chiropractic and orthopedic IME reports made a prima facie showing, but the providers' medical affidavits raised a triable issue of fact as to medical necessity, so the insurer's motion was denied.
Westcan Chiropractic, P.C. v Hertz Claim Mgt. (2015 NY Slip Op 51066(U)) Appellate Term, Second Department, July 13, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Denied the insurer summary judgment because, although its sworn peer review made the showing, the treating doctor's affidavit meaningfully referred to and rebutted the peer review, raising a triable issue.
Bronx Mega Care Med, PLLC v Federal Ins. Co. (2015 NY Slip Op 51060(U)) Appellate Term, Second Department, July 7, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed IME report gave a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to or rebut the IME conclusions.
Nova Acupuncture, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50914(U)) Appellate Term, Second Department, June 16, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report set forth a factual basis and medical rationale for lack of medical necessity and the provider submitted no medical rebuttal, so the insurer was entitled to summary judgment on two claims.
Xvv, Inc. v New York Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50791(U)) Appellate Term, Second Department, May 18, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion because the record showed a triable issue of fact as to whether the supplies were medically necessary.
Gaetane Physical Therapy, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50698(U)) Appellate Term, Second Department, May 1, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because the affirmed IME report set forth a factual basis and medical rationale, and the provider's principal, who did not indicate she had examined the assignor, offered no medical rebuttal.
Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50680(U)) Appellate Term, Second Department, May 1, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Although the insurer's affirmed peer review set forth a factual basis and medical rationale, the provider's doctor's affirmation raised a triable issue on medical necessity, so the insurer's motion was properly denied.
Meridian Acupuncture Care, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50681(U)) Appellate Term, Second Department, May 1, 2015Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to make a prima facie showing of lack of medical necessity because it relied on an IME report of a patient who was not the provider's assignor.
Rainbow Supply of NY, Inc. v Geico Gen. Ins. Co. (2015 NY Slip Op 50391(U)) Appellate Term, Second Department, March 16, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer's cross motion because its peer reviews with reviewer affidavits set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut them.
Top Choice Med., P.C. v Clarendon Natl. Ins. Co. (2015 NY Slip Op 50384(U)) Appellate Term, Second Department, March 12, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the parties' conflicting medical expert opinions raised a triable issue on medical necessity, so the insurer's motion on the second cause of action was properly denied.
Metropolitan Diagnostic Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50383(U)) Appellate Term, Second Department, March 12, 2015Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Denied the insurer's summary judgment motion because the provider's physician's affirmation was sufficient to raise a triable issue of fact as to whether the services were medically necessary.
Compas Med., P.C. v GEICO Ins. Co. (2014 NY Slip Op 51857(U)) Appellate Term, Second Department, December 19, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set out a factual basis and medical rationale, and the provider's doctor's affirmation did not meaningfully refer to or rebut it, so the insurer was granted summary judgment on that claim.
Bronx Park Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 51832(U)) Appellate Term, Second Department, December 17, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity and the provider did not rebut it.
Medical Assoc., P.C. v Geico Gen. Ins. Co. (2014 NY Slip Op 51829(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Found a triable issue of fact on medical necessity on the record, so the insurer's cross motion stayed denied and the provider's summary judgment was vacated.
Cherkin v Praetorian Ins. Co. (2014 NY Slip Op 51828(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Found a triable issue of fact on medical necessity on the record, so the insurer's summary judgment motion was properly denied.
Rainbow Supply of NY, Inc. v Geico Gen. Ins. Co. (2014 NY Slip Op 51827(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's cross motion because, on review of the record, a triable issue of fact existed regarding the medical necessity of the supplies.
EMC Health Prods., Inc. v Praetorian Ins. Co. (2014 NY Slip Op 51806(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Found a triable issue of fact on medical necessity of the supplies, so the insurer's cross motion for summary judgment should have been denied.
Market St. Surgical Ctr. v Praetorian Ins. Co. (2014 NY Slip Op 51804(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion and the limitation of trial to medical necessity because the record showed a triable issue of fact regarding the medical necessity of the services.
Arco Med. NY, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51800(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion as to one date of service because the record showed a triable issue of fact regarding the medical necessity of those services.
LMS Acupuncture, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51799(U)) Appellate Term, Second Department, December 17, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held a triable issue of fact existed as to the medical necessity of the services on the remaining claim, so the insurer was not entitled to summary judgment dismissing it.
Glenn Segal PT, P.C. v GEICO (2014 NY Slip Op 51301(U)) Appellate Term, Second Department, August 12, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because two IME reports set forth a factual basis and medical rationale for no further treatment and the provider's doctor's affidavit failed to meaningfully refer to or rebut them.
Parkview Med. & Surgical, P.C. v Geico Gen. Ins. Co. (2014 NY Slip Op 51270(U)) Appellate Term, Second Department, August 8, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's cross motion because, on review of the record, a triable issue of fact existed regarding the medical necessity of the services.
Ortho Prods. & Equipments, Inc. v Geico Gen. Ins. Co. (2014 NY Slip Op 51269(U)) Appellate Term, Second Department, August 8, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's cross motion properly denied because the record showed a triable issue of fact as to the medical necessity of the supplies, leaving medical necessity as the only issue for trial.
Quality Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 51268(U)) Appellate Term, Second Department, August 8, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because three affirmed peer reviews set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut their conclusions.
Ortho Prods. & Equip., Inc. v GEICO Gen. Ins. Co. (2014 NY Slip Op 51263(U)) Appellate Term, Second Department, August 8, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's cross motion properly denied because the record showed a triable issue of fact as to the medical necessity of the supplies, leaving medical necessity as the only issue for trial.
Promed Durable Equip., Inc. v GEICO Ins. (2014 NY Slip Op 51262(U)) Appellate Term, Second Department, August 8, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because two affirmed peer reviews set forth a factual basis and medical rationale for finding the supplies unnecessary and the provider did not rebut them.
Compas Med., P.C. v Geico Ins. Co. (2014 NY Slip Op 51259(U)) Appellate Term, Second Department, August 8, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the treating doctor's affidavit sufficient to raise a triable issue of fact on the claims denied for lack of medical necessity, so the insurer's cross motion should have been denied as to them.
B & Y Surgical Supplies, Inc. v American Tr. Ins. Co. (2014 NY Slip Op 51255(U)) Appellate Term, Second Department, August 8, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review set forth a factual basis and medical rationale for finding the supplies unnecessary and the provider offered no rebuttal.
Bernhard J. Sengstock, D.C., P.C. v GEICO (2014 NY Slip Op 51266(U)) Appellate Term, Second Department, August 8, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Upheld denial of the insurer's cross motion because the record presented a triable issue of fact regarding the medical necessity of the services.
Optimal Well-Being Chiropractic, P.C. v Utica Mut. Ins. Co. (2014 NY Slip Op 51233(U)) Appellate Term, Second Department, July 28, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held on review of the record that the insurer was not entitled to summary judgment on lack of medical necessity.
Quality Health Prods., Inc. v Travelers Indem. Co. (2014 NY Slip Op 51231(U)) Appellate Term, Second Department, July 28, 2014Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld it was error to preclude the insurer's expert witnesses on hearsay grounds because they need not prove the truth of the underlying medical records, and ordered a new trial limited to medical necessity.
Pollenex Servs., Inc. v GEICO Gen. Ins. Co. (2014 NY Slip Op 50953(U)) Appellate Term, Second Department, May 29, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's cross motion for summary judgment should have been denied because the record showed a triable issue of fact as to the medical necessity of the services.
New Way Med. Supply Corp. v GEICO Ins. Co. (2014 NY Slip Op 50880(U)) Appellate Term, Second Department, May 22, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because three affirmed peer reviews made a prima facie showing and no rebuttal affidavit was among the papers the lower court considered, nor did the provider's own motion include medical evidence.
Triumph Assoc. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50875(U)) Appellate Term, Second Department, May 22, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the IME doctor's affirmation made a prima facie showing, but the treating doctor's contradicting findings from an exam six days after the IME raised a triable issue on medical necessity.
Promed Durable Equip., Inc. v GEICO Ins. (2014 NY Slip Op 50872(U)) Appellate Term, Second Department, May 22, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the peer reviews set forth a factual basis and medical rationale, but the provider's doctor's affirmation raised a triable issue on medical necessity, so the insurer's cross motion was properly denied.
Avicenna Med. Arts, P.L.L.C. v GEICO Ins. Co. (2014 NY Slip Op 50871(U)) Appellate Term, Second Department, May 22, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because two sworn IME reports set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut them.
Diagnostic Radiographic Imaging v GEICO Gen. Ins. Co. (2014 NY Slip Op 50869(U)) Appellate Term, Second Department, May 22, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because two affirmed peer reviews set forth a factual basis and medical rationale for lack of medical necessity and the provider did not rebut them.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2014 NY Slip Op 50868(U)) Appellate Term, Second Department, May 22, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut its conclusions.
New Way Med. Supply Corp. v Geico Ins. Co. (2014 NY Slip Op 50776(U)) Appellate Term, Second Department, April 30, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's cross motion properly denied because the record showed a triable issue of fact as to the medical necessity of the services.
High Quality Med. Supplies, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 50775(U)) Appellate Term, Second Department, April 30, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer not entitled to summary judgment because the record showed a triable issue of fact as to the medical necessity of the supplies.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50773(U)) Appellate Term, Second Department, April 30, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to judgment on the EMS units, massager and heating pad because the peer reviews found them superfluous given ongoing therapy and the provider's doctor did not meaningfully address that, while his affirmation raised triable issues on the other supplies.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50772(U)) Appellate Term, Second Department, April 30, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to judgment on the later-dated supplies because its peer review gave a factual basis and rationale (an existing therapy plan made them unnecessary) that the provider's doctor did not meaningfully address; a triable issue remained for earlier supplies.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50771(U)) Appellate Term, Second Department, April 30, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's cross motion properly denied because the record showed a triable issue of fact as to the medical necessity of the services.
Rogy Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 50629(U)) Appellate Term, Second Department, April 7, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review with a factual basis and medical rationale established lack of medical necessity for three bills, and the provider offered no rebuttal.
All Borough Group Med. Supply, Inc. v Unitrin Advantage Ins. Co. (2014 NY Slip Op 50462(U)) Appellate Term, Second Department, March 17, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld dismissal after trial proper because the insurer's expert established lack of medical necessity from his independent review of the records, so admission of the inadmissible peer review reports did not warrant reversal, and the provider failed to rebut.
Advanced Orthopedics, PLLC v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50418(U)) Appellate Term, Second Department, March 11, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the parties' conflicting medical expert opinions raised a triable issue of fact as to lack of medical necessity, so the insurer's summary judgment motion was properly denied.
Martin Plutno v Travelers Ins. Co. (2014 NY Slip Op 50412(U)) Appellate Term, Second Department, March 11, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the chiropractor's sworn IME statement made a prima facie showing, but the treating chiropractor's sworn letter of medical necessity raised a triable issue of fact.
American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U)) Appellate Term, Second Department, February 28, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's sworn chiropractic peer review made a prima facie showing, but the treating chiropractor's sworn letter of medical necessity raised a question of fact, so summary judgment was denied.
Provvedere, Inc. v Republic W. Ins. Co. (2014 NY Slip Op 50219(U)) Appellate Term, Second Department, February 7, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer established lack of medical necessity at trial because its credited doctor gave a factual basis and medical rationale for finding the traction units unnecessary and the provider called no rebuttal witnesses.
Alev Med. Supply, Inc. v Government Employees Ins. Co. (2014 NY Slip Op 50130(U)) Appellate Term, Second Department, January 28, 2014Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld dismissal after trial proper because the insurer's doctor's testimony on medical necessity was properly admitted over a hearsay objection and the provider did not challenge its substance.
Comprehensive MRI of N.Y., P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50128(U)) Appellate Term, Second Department, January 27, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the parties' conflicting medical expert opinions raised a triable issue as to lack of medical necessity, so the insurer's summary judgment motion was properly denied.
Total Equip., LLC v Mercury Cas. Co. (2013 NY Slip Op 52220(U)) Appellate Term, Second Department, December 20, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report finding resolved injuries established lack of medical necessity for supplies dispensed after the denial's effective date, and the provider's attorney affirmation and prescription raised no triable issue.
Mollo Chiropractic, PLLC v American Commerce Ins. Co. (2013 NY Slip Op 23419) Appellate Term, Second Department, December 9, 2013Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the sworn peer review setting out a factual basis and medical rationale raised a triable issue of medical necessity, defeating the provider's summary judgment motion.
Avicenna Med. Arts, P.L.L.C. v GEICO Ins. Co. (2013 NY Slip Op 52010(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the unrebutted peer review showed the $1,916.46 nerve testing unnecessary, granting the insurer judgment on that bill, but its IME a year later did not address the other $590.01 testing, so that claim survived.
Rainbow Supply of NY, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 52009(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its peer review report and the reviewer's affidavit set forth a factual basis and medical rationale for lack of medical necessity of the supply, and the provider did not rebut it.
Advanced Med. Diagnostics of Queens, P.C. v GEICO Ins. Co. (2013 NY Slip Op 52004(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review report set forth a factual basis and medical rationale for lack of medical necessity, and the provider did not rebut that showing.
Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2013 NY Slip Op 52003(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review report set forth a factual basis and medical rationale for lack of medical necessity, and the provider did not rebut that showing.
ABA Chiropractic, P.C. v Geico Gen. Ins. Co. (2013 NY Slip Op 52002(U)) Appellate Term, Second Department, November 26, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Reversed summary judgment for the insurer, holding on review of the record that a triable issue of fact existed regarding the medical necessity of the services.
Alev Med. Supply, Inc. v Praetorian Ins. Co. (2013 NY Slip Op 51999(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to or rebut it, so the insurer won summary judgment.
Alev Med. Supply, Inc. v Praetorian Ins. Co. (2013 NY Slip Op 51995(U)) Appellate Term, Second Department, November 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to, let alone rebut, the peer review's conclusions.
Alev Med. Supply, Inc. v Travelers Home & Mar. Ins. Co. (2013 NY Slip Op 51759(U)) Appellate Term, Second Department, October 15, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because the provider's only challenge, an unsupported claim that the peer review bore a stamped signature, was insufficient to raise an issue of fact against the insurer's showing.
Elite Med. NY, P.C. v American Tr. Ins. Co. (2013 NY Slip Op 51738(U)) Appellate Term, Second Department, October 8, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale and the provider submitted no medical rebuttal, so the insurer was entitled to summary judgment on two claims.
Intuitive Chiropractic, P.C. v REdland Ins. Co. (2013 NY Slip Op 51461(U)) Appellate Term, Second Department, August 26, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review report set forth a factual basis and medical rationale for lack of medical necessity, and the provider failed to rebut that showing.
Right Aid Diagnostic Medicine, P.C. v Geico Ins. Co. (2013 NY Slip Op 51458(U)) Appellate Term, Second Department, August 26, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that, given the provider's doctor's affidavit opposing the cross motion, triable issues of fact existed as to medical necessity, so the insurer's cross motion was properly denied.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51377(U)) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review reports set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider offered no rebuttal.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51376(U)) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review reports set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider offered no rebuttal.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51375(U)) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld a sworn peer review with a factual basis and medical rationale made the showing; a doctor's affirmation raised an issue for one date but failed to meaningfully address the peer review's superfluous-supplies finding for the other, which was dismissed.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51374(U)) Appellate Term, Second Department, August 16, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's sworn and affirmed peer reviews set forth a factual basis and medical rationale, but the provider's doctor's affirmation raised a triable issue of medical necessity, so the insurer's cross motion was properly denied.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51373(U)) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld peer reviews with a factual basis and medical rationale made the showing; the doctor's affirmation raised issues for some supplies but failed to meaningfully address the finding that EMS units and a massager were superfluous given physical therapy, so those were dismissed.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51372(U)) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld peer reviews with a factual basis and medical rationale made the showing; the doctor's affirmation raised issues for some supplies but failed to meaningfully address the finding that EMS supplies were superfluous given physical therapy, so those were dismissed.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 51371(U)) Appellate Term, Second Department, August 16, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's affirmed peer reviews set forth a factual basis and medical rationale, but the provider's doctor's affirmation raised a triable issue of medical necessity, so the insurer's cross motion was properly denied.
Promed Durable Equip., Inc. v GEICO Ins. (2013 NY Slip Op 23283) Appellate Term, Second Department, August 16, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld peer reviews with a factual basis and medical rationale made the showing; a doctor's affirmation raised an issue for one date but failed to meaningfully address the superfluous-supplies finding for the other, which was dismissed.
Quality Health Prods. v GEICO Gen. Ins. Co. (2013 NY Slip Op 51118(U)) Appellate Term, Second Department, July 5, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer established a factual basis and medical rationale for lack of medical necessity of the supplies, and the provider submitted no medical evidence in rebuttal, so dismissal was affirmed.
Amato v State Farm Ins. Co. (2013 NY Slip Op 51113(U)) Appellate Term, Second Department, July 3, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld that the IME chiropractor's trial testimony that the assignor had reached pre-accident status shifted the burden to the provider, which offered no evidence, so judgment was directed for the insurer.
Alev Med. Supply, Inc. v Government Empls. Ins. Co. (2013 NY Slip Op 51096(U)) Appellate Term, Second Department, June 27, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal after trial because the insurer's expert testimony established lack of medical necessity unrebutted; admitting the peer review report, though not itself proof of lack of necessity, did not require reversal.
Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2013 NY Slip Op 51034(U)) Appellate Term, Second Department, June 17, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale and was not rebutted by the provider, so the insurer's cross motion should have been granted.
Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co. (2013 NY Slip Op 50904(U)) Appellate Term, Second Department, May 22, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the provider's contrary affirmed IME report raised a triable issue on eleven claims denied on the insurer's IME, though one claim denied on an unrebutted peer review was dismissed.
Right Aid Diagnostic Medicine, P.C. v Geico Ins. Co. (2013 NY Slip Op 50901(U)) Appellate Term, Second Department, May 22, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed peer review reports set forth a factual basis and medical rationale and the provider did not rebut them, so the insurer's cross motion should have been granted.
Eagle Surgical Supply, Inc. v GEICO Ins. Co. (2013 NY Slip Op 50854(U)) Appellate Term, Second Department, May 14, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal after trial because the insurer's expert testimony established lack of medical necessity of the supplies; admitting the peer review report, though not admissible to prove lack of necessity, did not warrant reversal.
Radiology Today, P.C. v Travelers Ins. Co. (2013 NY Slip Op 50849(U)) Appellate Term, Second Department, May 14, 2013Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Affirmed judgment for the provider after trial because the insurer's expert testified conclusorily without a factual basis or medical rationale, and the peer review report was not admissible to prove lack of necessity.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50764(U)) Appellate Term, Second Department, May 6, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review report set forth a factual basis and medical rationale for lack of medical necessity of the supply and the provider did not rebut it.
Park Slope Med. v Praetorian Ins. Co. (2013 NY Slip Op 50761(U)) Appellate Term, Second Department, May 6, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its sworn peer review explained the supplies were superfluous given ongoing therapy, and the provider's physician affirmation failed to meaningfully refer to or rebut it.
Jamaica Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50760(U)) Appellate Term, Second Department, May 6, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to or rebut it, so the insurer won summary judgment.
B & Y Surgical Supplies, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50759(U)) Appellate Term, Second Department, May 6, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held triable issues of fact existed as to the medical necessity of the supplies, so the insurer's cross motion was properly denied and the provider's motion should also have been denied.
Medical Assoc., P.C. v Unitrin Advantage Ins. Co. (2013 NY Slip Op 50757(U)) Appellate Term, Second Department, May 6, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the sworn peer reviews set forth a factual basis and medical rationale, but the provider's doctor's affirmations raised a triable issue of medical necessity, so both summary judgment motions were denied.
Baybenson Chiropractic, LLC v Clarendon Natl. Ins. (2013 NY Slip Op 50756(U)) Appellate Term, Second Department, May 6, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review and IME reports set forth a factual basis and medical rationale, and the provider's chiropractor's affidavit failed to meaningfully refer to or rebut them, so the insurer won summary judgment.
Kew Garden Imaging v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 50748(U)) Appellate Term, Second Department, May 6, 2013Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingReversed judgment for the provider and ordered a new trial because the trial court wrongly precluded the insurer's peer review doctors from testifying about the medical records they reviewed.
Jamaica Med. Plaza, P.C. v Interboro Ins. Co. (2013 NY Slip Op 50475(U)) Appellate Term, Second Department, March 29, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the treating physician's affirmation raised triable issues of fact as to the medical necessity of the services, so the insurer's summary judgment motion was properly denied.
Crotona Hgts. Med., P.C. v Clarendon Natl. Ins. Co. (2013 NY Slip Op 50473(U)) Appellate Term, Second Department, March 29, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale and the treating doctor's affidavit failed to meaningfully rebut them, so the insurer won summary judgment on three causes of action.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50454(U)) Appellate Term, Second Department, March 20, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld sworn peer reviews setting out a factual basis and medical rationale established lack of medical necessity for three assignors' services, and the provider offered no rebuttal, so dismissal was proper.
A-Quality Med. Supply v GEICO Gen. Ins. Co. (2013 NY Slip Op 23088) Appellate Term, Second Department, March 18, 2013Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the trial court wrongly disregarded the insurer's expert testimony over defects in undated or unsworn peer reviews; at trial necessity turns on expert testimony, and the peer review report itself is inadmissible.
New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50419(U)) Appellate Term, Second Department, March 15, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the provider's doctor's affidavit sufficiently demonstrated a question of fact as to medical necessity, so the insurer's cross motion for summary judgment on lack of medical necessity should have been denied.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50260(U)) Appellate Term, Second Department, February 19, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its chiropractors' affidavits and peer reviews set forth a factual basis and medical rationale for lack of medical necessity of the supplies, unrebutted by the provider.
Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50259(U)) Appellate Term, Second Department, February 19, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer's cross motion because its affirmed IME report set forth a factual basis and medical rationale for lack of necessity and the provider failed to meaningfully refer to, let alone rebut, its conclusions.
All Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co. (2013 NY Slip Op 50252(U)) Appellate Term, Second Department, February 19, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal because the provider's letter of medical necessity did not meaningfully refer to the psychologist peer reviewer's conclusions and an expert's general testimony from an unrelated trial about psychological testing was irrelevant to this peer review.
Medical Assoc., P.C. v Clarendon Natl. Ins. Co. (2013 NY Slip Op 50248(U)) Appellate Term, Second Department, February 19, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the provider's medical doctor's affirmation raised a triable issue of fact as to medical necessity, so the insurer's summary judgment motion should have been denied.
Jamaica Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50247(U)) Appellate Term, Second Department, February 19, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer reviewers' affirmations set forth a factual basis and medical rationale, their stamped signatures were placed by or at the doctors' direction and so admissible, and the provider offered no rebuttal.
Favorite Health Prods., Inc. v GEICO Ins. Co. (2013 NY Slip Op 50201(U)) Appellate Term, Second Department, February 11, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the affirmed peer reviews established lack of medical necessity, but the provider's doctor's affirmation raised a triable issue, so neither party was entitled to summary judgment.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 50199(U)) Appellate Term, Second Department, February 11, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report established lack of medical necessity and the provider failed to rebut it, so the IME-based claims were dismissed.
Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50197(U)) Appellate Term, Second Department, February 11, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports set forth a factual basis and medical rationale, and the provider left that showing unrebutted, so the insurer's cross motion was properly granted.
Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50196(U)) Appellate Term, Second Department, February 11, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld affirmed IME reports and a peer review setting forth a factual basis and medical rationale established lack of medical necessity for most dates of service, and the provider failed to rebut them.
Barakat Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50180(U)) Appellate Term, Second Department, February 1, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports set forth a factual basis and medical rationale, and the provider's doctor's affidavit failed to meaningfully refer to or rebut them, so the insurer won summary judgment.
Axis Chiropractic, PLLC v Geico Gen. Ins. Co. (2013 NY Slip Op 50068(U)) Appellate Term, Second Department, January 14, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed IME reports set forth a factual basis and medical rationale, and the provider submitted no medical professional's affidavit rebutting them, so the insurer won summary judgment.
Axis Chiropractic, PLLC v Geico Gen. Ins. Co. (2013 NY Slip Op 50067(U)) Appellate Term, Second Department, January 14, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale, and the provider submitted no medical professional's affidavit rebutting it, so the insurer won summary judgment.
Axis Chiropractic, PLLC v Geico Gen. Ins. Co. (2013 NY Slip Op 50066(U)) Appellate Term, Second Department, January 14, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale, and the provider submitted no medical professional's affidavit rebutting it, so the insurer won summary judgment.
Parsons Med. Supply, Inc. v Progressive Northeastern Ins. Co. (2013 NY Slip Op 50065(U)) Appellate Term, Second Department, January 14, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale for lack of necessity of the supplies, and the provider submitted no medical rebuttal, so the insurer won summary judgment.
Alfa Med. Supplies v GEICO Gen. Ins. Co. (2013 NY Slip Op 50064(U)) Appellate Term, Second Department, January 14, 2013Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the sworn peer review shifted the burden to the provider, but the provider's doctor's affidavit raised a question of fact as to medical necessity, so the insurer's cross motion should have been denied.
Quality Psychological Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50063(U)) Appellate Term, Second Department, January 14, 2013Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the psychologist's peer review inadmissible because a psychologist cannot affirm under CPLR 2106 and the notary stamp lacked any attestation of swearing, so the insurer's motion failed.
Alfa Med. Supplies v GEICO Gen. Ins. Co. (2012 NY Slip Op 52405(U)) Appellate Term, Second Department, December 21, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale for lack of necessity of the supplies (except a conceded thermophore), and the provider submitted no doctor's affirmation rebutting it.
Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U)) Appellate Term, Second Department, December 13, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion: its sworn peer review set forth a factual basis and medical rationale, but the provider's chiropractor's affidavit raised an issue of fact as to medical necessity.
VE Med. Care, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52262(U)) Appellate Term, Second Department, December 7, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review and IME reports set forth factual bases and medical rationales for lack of necessity and the provider failed to rebut them.
Quality Psychological Servs., P.C. v Travelers Ins. Co. (2012 NY Slip Op 52080(U)) Appellate Term, Second Department, October 25, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two sworn peer reviews set forth a factual basis and medical rationale for lack of necessity, and the provider's psychologist affidavit failed to meaningfully refer to, let alone rebut, their conclusions.
Complete Radiology, P.C. v Progressive Ins. Co. (2012 NY Slip Op 52079(U)) Appellate Term, Second Department, October 25, 2012Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's two affirmed peer reviews set forth a factual basis and medical rationale and sufficiently rebutted the provider's letter of medical necessity, creating an issue of fact that defeated the provider's motion.
Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51968(U)) Appellate Term, Second Department, October 11, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale establishing prima facie lack of necessity, and the provider submitted no medical evidence raising a triable issue.
Alfa Med. Supplies v Utica Mut. Ins. Co. (2012 NY Slip Op 51890(U)) Appellate Term, Second Department, September 28, 2012Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review, annexed to its opposition, was sufficient to require denial of the provider's summary judgment motion on the $2,199 supply claim.
Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51772(U)) Appellate Term, Second Department, September 5, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the acupuncturist's sworn IME report set forth a factual basis and medical rationale, and the treating acupuncturist's affidavit offered only a conclusory rebuttal.
Hollis Med. Servs., P.C. v GEICO Ins. Co. (2012 NY Slip Op 51768(U)) Appellate Term, Second Department, September 5, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports each set forth a factual basis and medical rationale for lack of necessity, and since the provider did not rebut that showing the insurer won summary judgment.
Alfa Med. Supplies v GEICO Gen. Ins. Co. (2012 NY Slip Op 51765(U)) Appellate Term, Second Department, September 5, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld three sworn peer reviews with a factual basis and medical rationale made an unrebutted showing, rejecting the stamped-signature objection because the signatures were placed by or at the direction of the reviewing doctors.
Five S & A Rehab Pt, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51724(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report demonstrated a factual basis and medical rationale for lack of necessity, and as the provider failed to rebut that showing the insurer was entitled to summary judgment.
Kamara Supplies, Inc. v Clarendon Ins. Co. (2012 NY Slip Op 51718(U)) Appellate Term, Second Department, August 31, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Affirmed denial of the insurer's cross motion because its affirmed peer review report failed to clearly establish a sufficient medical rationale and factual basis for lack of necessity of the supplies.
Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co. (2012 NY Slip Op 51713(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn chiropractic IME report set forth a factual basis and medical rationale for lack of necessity, and the unrebutted showing entitled the insurer to summary judgment.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51705(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale for lack of necessity of three services and, unrebutted, entitled the insurer to judgment on them, while an issue of fact remained on the diagnostic interview.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51704(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale for lack of necessity of the psychological services, and the unrebutted showing entitled the insurer to summary judgment.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51703(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale for lack of necessity of the psychological services, and the unrebutted showing entitled the insurer to summary judgment.
Axis Chiropractic, PLLC v GEICO Gen. Ins. Co. (2012 NY Slip Op 51702(U)) Appellate Term, Second Department, August 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn chiropractic IME report set forth a factual basis and medical rationale for lack of necessity, and the unrebutted showing entitled the insurer to summary judgment.
VE Med. Care, P.C. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51659(U)) Appellate Term, Second Department, August 27, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale for lack of necessity, and the provider did not rebut that prima facie showing.
North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U)) Appellate Term, Second Department, August 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on three claims because its affirmed IME and peer review reports set forth a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to them.
Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51655(U)) Appellate Term, Second Department, August 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports set forth a factual basis and medical rationale for lack of necessity on the four timely denied claims, and the provider left that showing unrebutted.
Acupuncture Works, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 51654(U)) Appellate Term, Second Department, August 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report established lack of medical necessity, and the provider's acupuncturist's affidavit did not meaningfully refer to or rebut it.
Northshore Chiropractic Diagnostics, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51646(U)) Appellate Term, Second Department, August 23, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion: its two affirmed peer reviews set forth a factual basis and medical rationale, but the provider's doctor's affidavit raised a question of fact as to medical necessity.
Village Chiropractic v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51640(U)) Appellate Term, Second Department, August 23, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion because the treating chiropractor's affidavit demonstrated a triable issue of fact as to the medical necessity of the services.
Neomy Med., P.C. v GEICO Ins. Co. (2012 NY Slip Op 51638(U)) Appellate Term, Second Department, August 23, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's cross motion: its affirmed peer review set forth a factual basis and medical rationale, but the provider's doctor's affidavit raised a question of fact as to medical necessity.
All Star Wellness Med., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51630(U)) Appellate Term, Second Department, August 7, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Held the affirmed peer review set forth a factual basis and medical rationale for lack of necessity of one bill and the provider raised no triable issue.
Brownsville Advance Med., P.C. v Kemper Independence Ins. Co. (2012 NY Slip Op 51629(U)) Appellate Term, Second Department, August 7, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a sufficient factual basis and medical rationale, shifting the burden, and the provider submitted no affidavit or affirmation from a medical professional in rebuttal.
Essential Acupuncture Servs., P.C. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51623(U)) Appellate Term, Second Department, August 7, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed IME report made a prima facie showing of lack of medical necessity for three claims, and the provider did not rebut it, entitling the insurer to dismissal of those claims.
Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2012 NY Slip Op 51490(U)) Appellate Term, Second Department, August 6, 2012Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial on one claim because the insurer's expert was wrongly precluded for not having written the peer review, and upheld the provider's verdict on the other because the court could reject the uncontradicted expert.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51447(U)) Appellate Term, Second Department, July 25, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews set forth a factual basis and medical rationale for lack of necessity of the billed services, and the provider left that showing unrebutted.
Alrof, Inc. v Praetorian Ins. Co. (2012 NY Slip Op 51445(U)) Appellate Term, Second Department, July 18, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on four claims because its affirmed peer reviews set forth a factual basis and medical rationale and the provider's doctor's affirmation failed to meaningfully refer to or rebut them.
Patchogue Physical Therapy, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51444(U)) Appellate Term, Second Department, July 18, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review set forth a factual basis and medical rationale for lack of necessity and the provider did not rebut that showing.
Midtown Med. Assoc., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51351(U)) Appellate Term, Second Department, July 13, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed IME reports set forth a factual basis and medical rationale for lack of necessity of the remaining services, and the provider's doctor's affidavit failed to meaningfully refer to, let alone rebut, them.
Park Slope Med. & Surgical Supply, Inc. v Travelers Ins. Co. (2012 NY Slip Op 22200) Leading case Appellate Term, Second Department, July 12, 2012Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the medical records the insurer's peer reviewer relied on were admissible to show what was conveyed to the insurer, not for their truth, so excluding them was error.
Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co. (2012 NY Slip Op 51296(U)) Appellate Term, Second Department, June 28, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report set forth a factual basis and medical rationale for lack of necessity of chiropractic treatment after the IME, unrebutted by the provider, but did not establish lack of necessity for earlier services.
3 Star Acupuncture, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51295(U)) Appellate Term, Second Department, June 28, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's cross motion on the acupuncture claims because there was a triable issue of fact regarding the medical necessity of the services.
Richmond Radiology, P.C. v State Farm Ins. Co. (2012 NY Slip Op 51293(U)) Appellate Term, Second Department, June 28, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that although the insurer's two sworn peer reviews set forth a factual basis and medical rationale, the treating chiropractor's affirmed letter of medical necessity raised a triable issue, so the insurer's cross motion should have been denied.
Megacure Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51291(U)) Appellate Term, Second Department, June 28, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report showed lack of medical necessity, and the provider's acupuncturist's affidavit failed to meaningfully refer to or rebut it, so the insurer got summary judgment.
Gentle Care Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51290(U)) Appellate Term, Second Department, June 28, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME report with the examiner's affidavit found the injuries resolved, and the provider's affidavit of medical necessity did not meaningfully refer to or rebut it.
Yklik, Inc. v Electric Ins. Co. (2012 NY Slip Op 51287(U)) Appellate Term, Second Department, June 28, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer reviews set forth a factual basis and medical rationale and the provider's doctor's affirmation failed to meaningfully refer to, let alone rebut, them.
Eagle Surgical Supply, Inc v Mercury Cas. Co. (2012 NY Slip Op 51286(U)) Appellate Term, Second Department, June 28, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's affirmed peer review lacked a factual basis and medical rationale because the reviewer merely asserted insufficient documentation, and the insurer had not sought the information through verification.
Midtown Med. Assoc., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51071(U)) Appellate Term, Second Department, June 11, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's motion properly denied because its affirmed peer review report failed to clearly establish a sufficient medical rationale and factual basis showing lack of medical necessity.
New Life Med., P.C. v GEICO Ins. Co. (2012 NY Slip Op 51061(U)) Appellate Term, Second Department, June 11, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its two affirmed peer reviews set forth a factual basis and medical rationale and the practitioner's opposing affidavit failed to meaningfully rebut their conclusions.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51057(U)) Appellate Term, Second Department, June 11, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed its prima facie showing because its peer review reports were affirmed by a psychologist, not permitted under CPLR 2106, and the notarized report lacked an attestation that the psychologist was sworn.
Alfa Med. Supplies v GEICO Gen. Ins. Co. (2012 NY Slip Op 50934(U)) Appellate Term, Second Department, May 15, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal on the unrebutted peer review, holding the reviewed records need not be annexed and the facsimile signature was admissible because the reviewing chiropractor placed it on the report.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51013(U)) Appellate Term, Second Department, May 14, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal on the unrebutted peer review, holding the insurer did not have to annex the medical records its peer reviewer examined to make its showing.
Eastern Star Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51010(U)) Appellate Term, Second Department, May 14, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale, and the provider's acupuncturist's affidavit failed to meaningfully refer to or rebut it.
BLR Chiropractic, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50882(U)) Appellate Term, Second Department, May 11, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review report and the reviewing chiropractor's affidavit established prima facie a lack of medical necessity, shifting the burden to the provider, which failed to rebut it, so the insurer's cross motion was granted.
Mike Supply, Inc. v Progressive Ins. Co. (2012 NY Slip Op 50872(U)) Appellate Term, Second Department, May 11, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Reversed summary judgment for the insurer because the provider's opposition demonstrated a triable issue of fact as to whether the supplies were medically necessary.
Sigma Psychological, P.C. v GEICO (2012 NY Slip Op 50868(U)) Appellate Term, Second Department, May 11, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its sworn peer review set forth a factual basis and medical rationale for finding the psychological services unnecessary and the provider offered no rebuttal.
Neomy Med., P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50769(U)) Appellate Term, Second Department, April 25, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review and reviewer's affidavit showed lack of medical necessity, and the supervising physician's affidavit failed to justify the additional studies with specificity, so it raised no issue of fact and the insurer won summary judgment.
Complete Radiology, P.C. v Geico Ins. Co. (2012 NY Slip Op 50752(U)) Appellate Term, Second Department, April 25, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal because the insurer's affirmed peer review reports each set forth a factual basis and medical rationale for finding the services unnecessary, and the provider's remaining contentions lacked merit.
Hong Tao Acupuncture, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 50678(U)) Appellate Term, Second Department, April 10, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on the later claims because its sworn and affirmed peer reviews set forth a factual basis and medical rationale and the provider failed to rebut them.
Med-Tech Prods., Inc. v Statewide Ins. Co. (2012 NY Slip Op 50584(U)) Appellate Term, Second Department, April 2, 2012Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the peer reviews sufficient and unrebutted if admissible, but remitted for a hearing on whether their stamped facsimile signatures were valid before the motions are decided anew.
Vincent Med. Servs., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 50431(U)) Appellate Term, Second Department, March 6, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld affirmed IME reports setting out a factual basis and medical rationale established lack of medical necessity, and the provider offered no rebuttal, so the insurer was granted summary judgment on most causes of action.
Complete Radiology, P.C. v GEICO Ins. Co. (2012 NY Slip Op 50419(U)) Appellate Term, Second Department, March 6, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Although the insurer made its prima facie showing, the treating physician's affirmed letter of medical necessity raised a triable issue, so summary judgment for the insurer was vacated.
Quality Health Prods. v GEICO Gen. Ins. Co. (2012 NY Slip Op 50415(U)) Appellate Term, Second Department, March 6, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal because the affirmed peer review set forth a factual basis and medical rationale, its facsimile signature was placed by the reviewing doctor, and the provider did not rebut it.
Queens Med. Supply, Inc. v Tri State Consumer Ins. Co. (2012 NY Slip Op 50414(U)) Appellate Term, Second Department, March 6, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its affirmed peer reviews set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider did not rebut them.
Crotona Hgts. Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 50401(U)) Appellate Term, Second Department, March 5, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, needed no hearsay foundation for the records reviewed, and was unrebutted because the provider submitted no doctor's affirmation, so the insurer won summary judgment.
Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2012 NY Slip Op 50394(U)) Appellate Term, Second Department, March 2, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer review was sufficient, the facsimile signature was placed by or at the direction of the reviewer, and the provider's affirmation did not meaningfully address it.
Medical Assoc., P.C. v Interboro Ins. Co. (2012 NY Slip Op 50392(U)) Appellate Term, Second Department, March 2, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity without a hearsay foundation for the underlying records, and the provider's only opposition was an unsworn medical report, so the insurer won summary judgment.
Park Slope Med. & Surgical Supply, Inc. v Progressive Ins. Co. (2012 NY Slip Op 50349(U)) Appellate Term, Second Department, February 21, 2012Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingOrdered a new trial because the insurer's expert, though not the author of the peer review, should have been allowed to testify on medical necessity, limited to the peer review's basis for denial.
New Life Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50346(U)) Appellate Term, Second Department, February 21, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its two affirmed peer reviews set forth a factual basis and medical rationale and the practitioner's opposing affidavit failed to meaningfully rebut them.
Quality Psychological Servs., P.C. v Clarendon Ins. Co. (2012 NY Slip Op 50345(U)) Appellate Term, Second Department, February 21, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Affirmed denial of the insurer's motion because the provider's psychologist's affidavit was sufficient to raise a triable issue of fact as to medical necessity.
Raz Acupuncture, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 50305(U)) Appellate Term, Second Department, February 14, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME examiner's sworn report gave a factual basis and medical rationale that further acupuncture was unnecessary, and being unrebutted, entitled the insurer to summary judgment on the later dates of service.
Elmont Open MRI & Diagnostic Radiology, P.C. v Tri-State Ins. Co. (2012 NY Slip Op 50170(U)) Appellate Term, Second Department, January 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review set forth a factual basis and medical rationale, the insurer did not have to annex the records the reviewer examined, and the provider failed to rebut it, so the insurer won summary judgment.
Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50155(U)) Appellate Term, Second Department, January 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itReversed and granted the insurer summary judgment because its affirmed IME report set forth a factual basis and medical rationale for lack of medical necessity of the supplies, and the provider did not rebut it.
Eagle Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50151(U)) Appellate Term, Second Department, January 24, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed its prima facie showing because its chiropractor's peer reviews were improperly affirmed and the notarized one lacked an attestation of oath, adding that the provider's osteopath affidavit would have rebutted them anyway.
New Life Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50150(U)) Appellate Term, Second Department, January 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment because its affirmed peer reviews set forth a factual basis and medical rationale and the provider's doctor's affirmation failed to meaningfully refer to or rebut them.
Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50149(U)) Appellate Term, Second Department, January 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity without annexing the reviewed records, and the provider's counsel's affirmation, with no practitioner's affidavit and no showing that discovery was needed, did not rebut it.
Radiology Today, P.C. v Mercury Ins. Co. (2012 NY Slip Op 50148(U)) Appellate Term, Second Department, January 24, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on its sufficient peer review because the owner-doctor's affirmation was inadmissible under CPLR 2106 and in any event did not meaningfully address the peer review.
Neomy Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50145(U)) Appellate Term, Second Department, January 24, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the affirmed peer review shifted the burden, but the provider's doctor's affidavit sufficiently demonstrated a question of fact as to medical necessity, so the insurer's cross motion was properly denied.
Elmont Open MRI & Diagnostic Radiology, P.C. v Tri State Consumer Ins. Co. (2012 NY Slip Op 50079(U)) Appellate Term, Second Department, January 17, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a sufficient factual basis and medical rationale, shifting the burden, and the provider submitted no medical evidence raising a triable issue, so the insurer was granted summary judgment.
Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50078(U)) Appellate Term, Second Department, January 17, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor's affidavit and IME report set forth a sufficient medical rationale and factual basis for lack of necessity of the equipment, and the provider filed no opposition, so the insurer's motion was granted.
SI Med. & Surgical Supply, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50054(U)) Appellate Term, Second Department, January 13, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale for lack of necessity of the supplies and were not rebutted by the provider, so the insurer's cross motion was granted.
Sky Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 50050(U)) Appellate Term, Second Department, January 13, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor/acupuncturist's affidavit and peer review set forth a factual basis and medical rationale that the supplies were unnecessary, and the provider did not rebut it, so the insurer won summary judgment.
MIA Acupuncture, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 21480) Appellate Term, Second Department, December 29, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the acupuncturist's sworn IME report established lack of medical necessity for post-IME services and the treating acupuncturist's affidavit did not rebut it, so the insurer was granted summary judgment on that portion.
Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52388(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a sufficient medical rationale and factual basis, shifting the burden, and the provider offered no medical evidence raising a triable issue, so the insurer won summary judgment.
Biobalance Med., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52378(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, and the provider offered no practitioner's affidavit meaningfully referring to or rebutting it, so the insurer won summary judgment on that cause of action.
High Quality Med., P.C. v GEICO Ins. Co. (2011 NY Slip Op 52373(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports showed lack of necessity, and the provider's doctor's affidavit failed to meaningfully refer to or rebut their conclusions, so the insurer's cross motion was granted.
ALROF, Inc. v Praetorian Ins. Co. (2011 NY Slip Op 52372(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld three sworn chiropractic peer review reports showed lack of necessity for the supplies, and the provider's doctor's affirmation failed to meaningfully refer to or rebut them, so the insurer's cross motion was granted.
W.H.O. Acupuncture, P.C. v National Cont. Ins. Co. (2011 NY Slip Op 52370(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report made a prima facie showing of lack of medical necessity, and the provider's claim of an issue of fact, raised first on appeal, was not considered.
Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2011 NY Slip Op 52367(U)) Appellate Term, Second Department, December 23, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, and with no practitioner's affidavit rebutting it the insurer's cross motion should have been granted.
Apple Tree Acupuncture, P.C. v Interboro Ins. Co. (2011 NY Slip Op 52364(U)) Appellate Term, Second Department, December 23, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the IME report and the examiner's affidavit established lack of necessity, but the provider's acupuncturist's affidavit raised a triable issue, defeating partial summary judgment.
Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 52355(U)) Appellate Term, Second Department, December 21, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a factual basis and medical rationale for lack of necessity of the supplies, which the provider did not rebut, so the insurer's cross motion was granted.
Ave P Rehab & Med. Plaza, P.C. v Geico Ins. Co. (2011 NY Slip Op 52301(U)) Appellate Term, Second Department, December 19, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld three affirmed peer review reports set forth a factual basis and medical rationale for lack of necessity, which the provider did not rebut, so the insurer's cross motion for summary judgment was granted.
Park Slope Med. & Surgical Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 52300(U)) Appellate Term, Second Department, December 19, 2011Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the trial court erred in precluding the insurer's expert, who had not written the peer review, from testifying on medical necessity limited to the report's basis, and ordered a new trial.
Quality Health Prods. v Geico Gen. Ins. Co. (2011 NY Slip Op 52299(U)) Appellate Term, Second Department, December 19, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, its facsimile signature was admissible because placed by or at the reviewer's direction, and no doctor's rebuttal was submitted, so the insurer won summary judgment.
All Points Med. Supply, Inc. v Clarendon Ins. Co. (2011 NY Slip Op 52292(U)) Appellate Term, Second Department, December 19, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale for lack of necessity of the supplies, which the provider did not rebut, so the insurer won dismissal of four causes of action.
Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 52290(U)) Appellate Term, Second Department, December 19, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a factual basis and medical rationale for lack of necessity of the supplies, which the provider did not rebut, so the insurer's cross motion was granted.
Comfort Supply, Inc. v Progressive Northeastern Ins. Co. (2011 NY Slip Op 52289(U)) Appellate Term, Second Department, December 19, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity for the equipment even without the underlying records annexed, and the provider failed to rebut it, so summary judgment for the insurer was affirmed.
Queens Med. Supply, Inc. v Geico Gen. Ins. Co. (2011 NY Slip Op 52284(U)) Appellate Term, Second Department, December 16, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, its facsimile signature was admissible because placed by or at the reviewer's direction, and no doctor's rebuttal was submitted, so summary judgment for the insurer was affirmed.
Alfa Med. Supplies v Eveready Ins. Co. (2011 NY Slip Op 52282(U)) Appellate Term, Second Department, December 16, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a factual basis and medical rationale for lack of necessity of the supplies, which the provider did not rebut, so the insurer's cross motion was granted.
City Dental Servs., P.C. v New York Cent. Mut. (2011 NY Slip Op 52285(U)) Appellate Term, Second Department, December 16, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's affirmed peer review report insufficient to demonstrate prima facie that the billed services were not medically necessary, so its motion to dismiss that cause of action was properly denied.
All Is. Med. Care, P.C. v State Farm Mut. Auto. Ins. Co. (2011 NY Slip Op 52227(U)) Appellate Term, Second Department, December 8, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's doctor's trial testimony and admitted peer review report established lack of medical necessity, and the provider called no rebuttal witnesses, so dismissal of the complaint was affirmed.
Parsons Med. Supply, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 52198(U)) Appellate Term, Second Department, November 30, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, its reliance on the provider's own and other providers' records did not make it inadmissible, and the provider failed to rebut it.
Alrof, Inc. v Progressive Ins. Co. (2011 NY Slip Op 21419) Appellate Term, Second Department, November 17, 2011Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the insurer's peer review doctor should have been allowed to testify about the medical records he reviewed and his opinion of no medical necessity, because the insurer need not establish the records' reliability or truth; new trial ordered.
Foster Diagnostic Imaging, P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52074(U)) Appellate Term, Second Department, November 4, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn chiropractic peer review report set forth a factual basis and medical rationale for lack of necessity, which the provider did not rebut, so the insurer's motion should have been granted.
AKS Med., P.C. v Clarendon Ins. Co. (2011 NY Slip Op 52072(U)) Appellate Term, Second Department, November 4, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that although the insurer made a prima facie showing of lack of medical necessity, the treating physician's opposing affidavit raised a triable issue, so the insurer's motion was properly denied.
Excellassist Med., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52071(U)) Appellate Term, Second Department, November 4, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itRejected the provider's sole contention that the peer review report was insufficient and held it established the insurer's entitlement to summary judgment for lack of medical necessity.
Morris Park Chiropractic, P.C. v American Tr. Ins. Co. (2011 NY Slip Op 52017(U)) Appellate Term, Second Department, October 27, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report showed lack of necessity, and the provider's chiropractor's affidavit failed to meaningfully refer to or rebut its conclusions, so the insurer won dismissal of the post-IME claims.
Complete Radiology, P.C. v Progressive Ins. Co. (2011 NY Slip Op 52015(U)) Appellate Term, Second Department, October 27, 2011Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report, setting forth a factual basis and medical rationale, properly defeated the provider's summary judgment motion, while declining to search the record and grant the insurer judgment.
Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52014(U)) Appellate Term, Second Department, October 27, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report showed lack of necessity for the supplies and was not rebutted, rejecting the argument that the provider lacked the documents the reviewer relied on, so the insurer won.
Van Courtland Med. Care, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 52013(U)) Appellate Term, Second Department, October 27, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a factual basis and medical rationale for lack of necessity, which the provider did not rebut, so the insurer won dismissal of the claim at issue.
MSSA Corp. v American Tr. Ins. Co. (2011 NY Slip Op 51997(U)) Appellate Term, Second Department, October 26, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review report set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider offered no rebuttal.
Trimed Med. Supply, Inc. v American Tr. Ins. Co. (2011 NY Slip Op 51880(U)) Appellate Term, Second Department, October 18, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity of the supplies on three claims, and the provider did not rebut it, so those claims were dismissed.
Mosad Med., P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51876(U)) Appellate Term, Second Department, October 18, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review report showed lack of medical necessity and the provider's doctor's affirmation failed to meaningfully refer to, let alone rebut, the report's conclusions.
MSSA Corp. v American Tr. Ins. Co. (2011 NY Slip Op 51864(U)) Appellate Term, Second Department, October 14, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review report set forth a factual basis and medical rationale for lack of medical necessity of the supplies, and the provider did not rebut it.
Radiology Imaging of Queens v Progressive Ins. (2011 NY Slip Op 51860(U)) Appellate Term, Second Department, October 14, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review report set forth a factual basis and medical rationale for lack of medical necessity, establishing the insurer's prima facie case on an unopposed motion, so summary judgment should have been granted.
Crotona Hgts. Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51859(U)) Appellate Term, Second Department, October 12, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME and peer review reports set forth a factual basis and medical rationale for lack of medical necessity, and because the provider did not rebut them the insurer was granted summary judgment on those claims.
Five Boro Psychological Servs., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51858(U)) Appellate Term, Second Department, October 12, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale, shifting the burden to the provider, whose failure to rebut it entitled the insurer to summary judgment.
Alfa Medical Supplies, Inc.. v Auto One Ins. Co. (2011 NY Slip Op 51851(U)) Appellate Term, Second Department, October 12, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed peer reviews established lack of medical necessity for the equipment, were not inadmissible for relying on other providers' records, and the provider failed to rebut them.
Fine Healing Acupuncture, P.C., v Country-Wide Ins. Co. (2011 NY Slip Op 21361) Appellate Term, Second Department, October 12, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the neurologist's IME supplied a factual basis and medical rationale shifting the burden, notwithstanding his different specialty, but the treating acupuncturist's affidavit raised a triable issue, so the insurer's cross motion was denied.
Points of Health Acupuncture, P.C. v GEICO Ins. Co. (2011 NY Slip Op 51843(U)) Appellate Term, Second Department, October 11, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's peer review reports and reviewers' affidavits set forth a factual basis and medical rationale for lack of necessity, and the provider submitted no opposition, so those claims were dismissed.
Z.A. Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 51842(U)) Appellate Term, Second Department, October 11, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the acupuncturist's sworn IME report established prima facie lack of necessity for post-IME services, and the provider submitted no opposition or admissible evidence of necessity, so those claims were dismissed.
Radiology Today, P.C. v Progressive Ins. Co. (2011 NY Slip Op 51724(U)) Appellate Term, Second Department, September 16, 2011Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the trial court erred in precluding the insurer's medical expert merely because he was not the author of the peer review report, and ordered a new trial without reaching the report's admissibility.
PSW Chiropractic Care, P.C. v Maryland Cas. Co. (2011 NY Slip Op 51719(U)) Appellate Term, Second Department, September 16, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Upheld the finding after trial that the insurer failed to prove the chiropractic treatment unnecessary, deferring to the trial court's assessment of the credibility of the insurer's IME doctor.
MSSA Corp. v Redland Ins. Co. (2011 NY Slip Op 51606(U)) Appellate Term, Second Department, August 16, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and the reviewer's affirmation set forth a factual basis and medical rationale, and the provider offered no practitioner affidavit meaningfully referring to it, so the insurer won summary judgment.
Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 51603(U)) Appellate Term, Second Department, August 16, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report set forth a factual basis and medical rationale for lack of medical necessity and the provider offered no medical rebuttal, so the insurer was granted summary judgment on that claim.
Manhattan Med. Imaging, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51541(U)) Appellate Term, Second Department, August 5, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld, reversing the lower court's finding that the peer review was insufficient, that the affirmed peer review report set forth a factual basis and medical rationale for lack of medical necessity and was unrebutted, entitling the insurer to summary judgment.
Neomy Med., P.C. v GEICO Ins. Co. (2011 NY Slip Op 51532(U)) Appellate Term, Second Department, August 4, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review established lack of medical necessity without annexing the reviewed records, which were not offered for their truth, and the provider failed to rebut it.
Ozone Park Chiropractic v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51453(U)) Appellate Term, Second Department, July 28, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the treating chiropractor's affidavit raised a triable issue of fact in opposition to the insurer's prima facie showing of lack of medical necessity, so the insurer's motion was properly denied as to those claims.
MSSA Corp. v American Tr. Ins. Co. (2011 NY Slip Op 51318(U)) Appellate Term, Second Department, July 8, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its affirmed peer review reports set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider did not rebut them.
Psychology YM, P.C. v Geico Gen. Ins. Co. (2011 NY Slip Op 51316(U)) Appellate Term, Second Department, July 8, 2011Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld it was error to preclude the peer reviewing psychologist from testifying about the factual basis and rationale for his opinion merely because his report was not in admissible form, since he was subject to cross-examination; new trial ordered.
Manhattan Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51230(U)) Appellate Term, Second Department, June 30, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews set forth a factual basis and medical rationale, and the provider offered no doctor's rebuttal; its unexplained claim of a stamped signature raised no issue.
Five Boro Psychological Servs., P.C. v Utica Mut. Ins. Co. (2011 NY Slip Op 51119(U)) Appellate Term, Second Department, June 14, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review reports set forth a factual basis and medical rationale for lack of medical necessity and the provider failed to rebut them, so the insurer won summary judgment on two bills.
Rogy Med., P.C. v Geico Ins. Co. (2011 NY Slip Op 50990(U)) Appellate Term, Second Department, May 26, 2011Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report, setting forth a factual basis and medical rationale, raised a triable issue of fact on medical necessity, so the provider's summary judgment motion was denied on that claim.
We Do Care Med. Supply, Inc. v American Tr. Ins. Co. (2011 NY Slip Op 50784(U)) Appellate Term, Second Department, April 26, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its peer review reports set forth factual bases and medical rationales for lack of medical necessity of the supplies and the provider did not rebut them.
We Do Care Med. Supply, P.C. v American Tr. Ins. Co. (2011 NY Slip Op 50783(U)) Appellate Term, Second Department, April 26, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its IME report set forth a factual basis and medical rationale for lack of medical necessity of the supplies and the provider did not rebut it.
Alur Med. Supply, Inc. v GEICO Ins. Co. (2011 NY Slip Op 50438(U)) Appellate Term, Second Department, March 15, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the affirmed peer reviews established lack of medical necessity prima facie, but the provider's doctor's affirmation raised a triable issue, so the provider's motion was denied and the insurer's cross motion stayed denied.
Bath Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 50189(U)) Appellate Term, Second Department, February 14, 2011Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer entitled to summary judgment because its peer review reports set forth a factual basis and medical rationale for lack of medical necessity and the provider offered no practitioner's affidavit meaningfully referring to or rebutting them.
Park Slope Med. & Surgical Supply, Inc. v GEICO Ins. Co. (2011 NY Slip Op 50188(U)) Appellate Term, Second Department, February 14, 2011Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that although the insurer's two admissible peer review reports set forth a factual basis and medical rationale, the provider's doctor's affirmation raised a question of fact as to medical necessity, so the insurer's cross motion was properly denied.
Bath Med. Supply, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52316(U)) Appellate Term, Second Department, December 23, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two peer review reports in admissible form, with a factual basis and medical rationale, established lack of medical necessity, and the provider failed to rebut them or show it needed the reviewers' underlying documents under CPLR 3212(f).
Gentle Care Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 52226(U)) Appellate Term, Second Department, December 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Held the IME reports and affidavits established lack of medical necessity for post-IME services, and the provider's affidavit did not meaningfully refer to or rebut them, so the insurer was granted summary judgment on those charges.
Elmont Open MRI & Diagnostic Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52222(U)) Appellate Term, Second Department, December 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity prima facie although the underlying records were not annexed, since the records were not offered for their truth, and the provider raised no triable issue.
Elmont Open MRI & Diagnostic Radiology, P.C. v Travelers Indem. Co. (2010 NY Slip Op 52223(U)) Appellate Term, Second Department, December 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, its reliance on other providers' records was not hearsay use, and the provider offered nothing raising a triable issue, so the insurer won summary judgment.
Complete Radiology, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52158(U)) Appellate Term, Second Department, December 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld 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.
Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2010 NY Slip Op 52157(U)) Appellate Term, Second Department, December 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed peer reviews set forth a factual basis and medical rationale for lack of medical necessity, and the provider submitted no opposition, so the insurer's cross motion should have been granted.
Iav Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 52155(U)) Appellate Term, Second Department, December 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity of the supplies, and the provider, not opposing, raised no triable issue.
Vincent Med. Servs., P.C. v GEICO Ins. Co. (2010 NY Slip Op 52153(U)) Appellate Term, Second Department, December 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports set out a factual basis and medical rationale, and the treating doctor's affidavit did not meaningfully refer to or rebut them, so the insurer was granted summary judgment on those claims.
Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U)) Appellate Term, Second Department, November 26, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld, contrary to the lower court, that the chiropractor's affidavit and peer review set forth a sufficient factual basis and medical rationale, and the provider submitted no medical evidence raising a triable issue.
Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52061(U)) Appellate Term, Second Department, November 26, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld, contrary to the lower court, that the affirmed peer review set forth a sufficient factual basis and medical rationale, and the provider offered no medical evidence raising a triable issue.
Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52060(U)) Appellate Term, Second Department, November 26, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's sworn peer review report, with a factual basis and medical rationale, showed the medical equipment was not medically necessary, and the provider offered no rebuttal, entitling the insurer to summary judgment.
Pomona Med. Diagnostics, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52059(U)) Appellate Term, Second Department, November 26, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two affirmed peer review reports with a factual basis and medical rationale established lack of medical necessity; the provider did not oppose, and its claimed rebuttal letter was not in the record or considered below.
Delta Diagnostic Radiology, P.C. v Interboro Ins. Co. (2010 NY Slip Op 52022(U)) Appellate Term, Second Department, November 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor's affirmed peer review set forth a factual basis and medical rationale, the provider waived the affirmation defect by not opposing, and its failure to rebut entitled the insurer to dismissal.
Radiology Today, P.C. v Mercury Ins. Co. (2010 NY Slip Op 52020(U)) Appellate Term, Second Department, November 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews established lack of medical necessity prima facie, and the provider's doctor's affirmation did not meaningfully refer to or rebut them, so summary judgment for the insurer was adhered to.
Crotona Hgts. Med., P.C. v Mercury Ins. Co. (2010 NY Slip Op 52019(U)) Appellate Term, Second Department, November 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews established lack of medical necessity for four causes of action and the provider's principal's affirmation was inadmissible under CPLR 2106, though one claim survived because no report addressed it.
Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52015(U)) Appellate Term, Second Department, November 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review set forth a factual basis and medical rationale, and the provider practitioner's affidavit failed to meaningfully refer to or rebut it, so the insurer's unopposed motion should have been granted.
Richmond Radiology, P.C. v Travelers Ins. Co. (2010 NY Slip Op 51964(U)) Appellate Term, Second Department, November 12, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor's affidavit and peer review set forth a factual basis and medical rationale for lack of medical necessity of the testing, and the provider offered no practitioner affidavit meaningfully referring to or rebutting it.
High Quality Med., P.C. v Mercury Ins. Co. (2010 NY Slip Op 51900(U)) Appellate Term, Second Department, November 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME doctor's affidavit and affirmed IME report established lack of medical necessity, and the provider's principal's affirmation was inadmissible under CPLR 2106 and in any event did not meaningfully refer to the IME conclusions.
MIA Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 51899(U)) Appellate Term, Second Department, November 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME acupuncturist's sworn report established lack of medical necessity for post-examination services and the treating acupuncturist's affidavit did not meaningfully refer to or rebut it.
Olga Bard Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 51898(U)) Appellate Term, Second Department, November 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME acupuncturist's sworn report established lack of medical necessity for post-examination services, and the treating acupuncturist's affidavit did not meaningfully refer to or rebut it, so those claims were dismissed.
Vinings Spinal Diagnostic, P.C. v Geico Gen. Ins. Co. (2010 NY Slip Op 51897(U)) Appellate Term, Second Department, November 8, 2010Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that although the affirmed peer review set forth a factual basis and medical rationale, the provider's chiropractor-owner's affidavit meaningfully referred to and rebutted it, raising a triable issue that defeated the provider's own motion.
Active Imaging, P.C. v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51842(U)) Appellate Term, Second Department, October 20, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, the insurer need not annex the records the reviewer relied on, and the provider failed to rebut it or justify discovery under CPLR 3212 (f).
Friendly Physician, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51772(U)) Appellate Term, Second Department, October 5, 2010Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held that denials based on an annexed verified peer review and affirmed IME reports finding no medical necessity showed a meritorious defense and raised a triable issue defeating the provider's summary judgment motion.
Park Slope Med. & Surgical Supply, Inc. v GEICO Ins. Co. (2010 NY Slip Op 51771(U)) Appellate Term, Second Department, October 5, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review setting out a factual basis and medical rationale raised a triable issue of medical necessity, so the provider's summary judgment motion should have been denied.
Manhattan Med. Imaging, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51737(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review setting out a factual basis and medical rationale raised a triable issue of medical necessity, so the provider's motion was denied.
I.V. Med. Supply, Inc. v Mercury Ins. Group (2010 NY Slip Op 51736(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review and the reviewing chiropractor's affidavit set forth a factual basis and medical rationale, and the provider, offering only counsel's affirmation, failed to rebut it.
Alfa Med. Supplies v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51733(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review, properly considered, set forth a factual basis and medical rationale, and the provider submitted no practitioner's affidavit in rebuttal, so the insurer won summary judgment on that claim.
MIA Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51731(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the IME acupuncturist's affidavit and examination report raised a triable issue of fact on lack of medical necessity, so the provider was not entitled to summary judgment on the IME-based claims.
St. Vincent Med. Care, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51728(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation did not meaningfully refer to or rebut it.
Neomy Med., P.C. v Auto One Ins. Co. (2010 NY Slip Op 51727(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review setting out a factual basis and medical rationale raised a triable issue of medical necessity, so summary judgment for the provider on the $3,551.02 claim was denied.
Altair Med., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51721(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld an affirmed peer review established lack of medical necessity for one claim the provider did not rebut, but an unsigned peer review failed to establish the insurer's prima facie case on the other claims.
Mutual Care Med. Supply, Inc. v Mercury Cas. Co. (2010 NY Slip Op 51734(U)) Appellate Term, Second Department, October 1, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review reports and reviewer's affidavit set forth a factual basis and medical rationale, and the provider offered no practitioner's affidavit meaningfully referring to them, so the insurer won summary judgment.
Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 51467(U)) Appellate Term, Second Department, August 13, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed its prima facie burden because its own moving papers were contradictory: the peer review found the MRIs unnecessary, but its IME report found one MRI necessary and other reports contradicted the peer review's facts.
Mega Supply & Billing, Inc. v Larendon Natl. Ins. Co. (2010 NY Slip Op 51452(U)) Appellate Term, Second Department, August 12, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, the provider offered no doctor's rebuttal, and its lack of the reviewer's records did not justify relief under CPLR 3212 (f).
Yklik, Inc. v GEICO Ins. Co. (2010 NY Slip Op 51336(U)) Appellate Term, Second Department, July 22, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews set forth a factual basis and medical rationale, and the provider's doctor's affirmation did not meaningfully refer to, let alone rebut, their conclusions.
Alfa Med. Supplies, Inc. v GEICO Gen. Ins. Co. (2010 NY Slip Op 51332(U)) Appellate Term, Second Department, July 22, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the provider's motion should have been denied because the insurer's affirmed peer review reports set forth a factual basis and medical rationale for lack of medical necessity and were unrebutted.
Neomy Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 51252(U)) Appellate Term, Second Department, July 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity and the provider failed to rebut it, so the insurer was granted summary judgment on that claim.
Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 51246(U)) Appellate Term, Second Department, July 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld 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.
Urban Radiology, P.C. v Tri-State Consumer Ins. Co. (2010 NY Slip Op 50987(U)) Appellate Term, Second Department, June 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, that reliance on the provider's and other providers' records was proper because they were not offered for their truth, and that the provider raised no triable issue.
Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2010 NY Slip Op 50997(U)) Appellate Term, Second Department, June 4, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, and the provider failed to rebut it or show under CPLR 3212 (f) that discovery of the reviewer's records was needed.
Innovative Chiropractic, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50994(U)) Appellate Term, Second Department, June 4, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review chiropractor's affidavit and report set forth a factual basis and medical rationale, and the provider did not rebut the showing, so the insurer's cross motion was granted.
Innovative Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 50884(U)) Appellate Term, Second Department, May 13, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review and IME reports made a prima facie showing, and the treating doctor's conclusory reaffirmation of necessity, not addressing the insurer's chiropractors, raised no triable issue.
We Care Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 50831(U)) Appellate Term, Second Department, May 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on the third cause of action because its affirmed peer review set forth a factual basis and medical rationale and the provider failed to rebut it.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50829(U)) Appellate Term, Second Department, May 10, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review reports set forth a sufficient factual basis and medical rationale to raise an issue of fact as to medical necessity, so the provider's motion should have been denied.
Speciality Surgical Servs. v Travelers Ins. Co. (2010 NY Slip Op 50715(U)) Appellate Term, Second Department, April 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld, reversing a trial judgment, that the insurer's doctor's testimony and affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity and were unrebutted, so judgment was directed for the insurer.
Alur Med. Supply, Inc. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 50700(U)) Appellate Term, Second Department, April 13, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld an affirmed peer review report with a factual basis and medical rationale established lack of medical necessity prima facie and shifted the burden; the provider, conceding only a triable issue, offered no rebuttal, so the insurer won.
Park Slope Med. & Surgical Supply, Inc. v GEICO Ins. Co. (2010 NY Slip Op 50650(U)) Appellate Term, Second Department, April 9, 2010Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the provider's doctor's affirmation, if admissible, sufficed to raise a triable issue against the insurer's peer review, and remitted for a hearing on whether its signature was a stamped facsimile before redeciding the insurer's cross motion.
Quality Psychological Servs., P.C. v Mercury Ins. Group (2010 NY Slip Op 50601(U)) Appellate Term, Second Department, April 2, 2010Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the sworn peer review made a prima facie showing, but the examining psychologist's sworn letter of medical necessity raised a triable issue, so both parties' motions were denied.
Delta Diagnostic Radiology, P.C. v Liberty Mut. Ins. Co. (2010 NY Slip Op 50597(U)) Appellate Term, Second Department, April 2, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer reviews made a prima facie showing of no medical necessity that the provider failed to rebut, supporting vacatur of the default and summary judgment for the insurer.
Laperla Supply, Inc. v Progressive Northwestern Ins. Co. (2010 NY Slip Op 50586(U)) Appellate Term, Second Department, March 31, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale that the provider failed to rebut, so the insurer's cross motion was granted.
Prime Psychological Servs., P.C. v Mercury Ins. Group (2010 NY Slip Op 50585(U)) Appellate Term, Second Department, March 31, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn psychologist's peer review set forth a factual basis and medical rationale, and the provider's psychologist's affirmation did not meaningfully refer to, let alone rebut, its conclusions.
Ortho-Med Surgical Supply, Inc. v Mercury Cas. Co. (2010 NY Slip Op 50587(U)) Appellate Term, Second Department, March 31, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review established lack of medical necessity because the provider's only opposition, a conclusory assertion that the reviewer's signature was stamped, gave no basis for that belief and raised no issue of fact.
Gz Med. & Diagnostic, P.C. v Mercury Ins. Co. (2010 NY Slip Op 50491(U)) Appellate Term, Second Department, March 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation did not meaningfully refer to or rebut it, so partial summary judgment went to the insurer.
Advanced Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 50454(U)) Appellate Term, Second Department, March 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME doctor's affirmation and report established prima facie that the services in two causes of action were not medically necessary, and the showing was unrebutted, so those claims were dismissed.
Favorite Health Prods., Inc. v Geico Ins. Co. (2010 NY Slip Op 50453(U)) Appellate Term, Second Department, March 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld two sworn peer reviews giving a factual basis and medical rationale showed the supplies were not medically necessary, and the provider offered no rebuttal, so the complaint was dismissed.
Co-Op City Chiropractic, P.C. v Mercury Ins. Group (2010 NY Slip Op 50452(U)) Appellate Term, Second Department, March 10, 2010Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's chiropractor's peer review set forth a factual basis and medical rationale, but the treating chiropractor's opposing affidavit raised a triable issue of fact on medical necessity, so the insurer's motion was properly denied.
High Quality Med., P.C. v Mercury Ins. Co. (2010 NY Slip Op 50447(U)) Appellate Term, Second Department, March 10, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a factual basis and medical rationale, and the provider's doctor's affirmation did not meaningfully refer to or rebut it, so the insurer won summary judgment on that claim.
Right Aid Diagnostic Medicine, P.C. v Geico Ins. Co. (2010 NY Slip Op 50445(U)) Appellate Term, Second Department, March 10, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report, setting forth a factual basis and medical rationale that the MRI was unnecessary, raised a triable issue, but declined to search the record and grant the insurer judgment.
Infinity Health Prods., Ltd. v Mercury Ins. Co. (2010 NY Slip Op 50385(U)) Appellate Term, Second Department, March 8, 2010Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the chiropractor's peer review made a prima facie showing of no medical necessity, but the provider's doctor's affirmation raised a triable issue, so the insurer's cross motion was properly denied.
Doshi Diagnostic Imaging Servs., P.C. v Mercury Ins. Group (2010 NY Slip Op 50384(U)) Appellate Term, Second Department, March 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed IME report made a prima facie showing of lack of medical necessity, and the provider's only rebuttal, an affirmation by its own principal, was improper under CPLR 2106 and could not raise a triable issue.
Eastern Star Acupuncture, P.C. v Mercury Ins. Co. (2010 NY Slip Op 50380(U)) Appellate Term, Second Department, March 8, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME examiner's affidavit and affirmed IME report established lack of medical necessity, and the provider's supervising acupuncturist's affirmation did not meaningfully refer to or rebut the IME conclusions, so the insurer won those claims.
Eden Med., P.C. v Eveready Ins. Co. (2010 NY Slip Op 50265(U)) Appellate Term, Second Department, February 19, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itUpheld summary judgment for the insurer on its affirmed peer review because the provider's bare claim that the reviewer's signature was a stamped facsimile raised no issue of fact, and the reviewer swore she signed it personally.
Progressive Med., Inc. v Allstate Ins. Co. (2010 NY Slip Op 50219(U)) Appellate Term, Second Department, February 5, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Upheld striking the insurer's peer doctor's trial testimony as hearsay because the insurer did not show the out-of-court documents he relied on were not offered for their truth or fell within an exception, so the provider recovered.
B.Y., M.D., P.C. v Progressive Cas. Ins. Co. (2010 NY Slip Op 50144(U)) Appellate Term, Second Department, January 28, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review and IME reports set forth a factual basis and medical rationale, and the treating doctor's incomplete affirmation did not meaningfully refer to them, so the insurer's cross motion was properly granted.
Canarsie Family Med. Practice, PLLC v American Tr. Ins. Co. (2010 NY Slip Op 50070(U)) Appellate Term, Second Department, January 12, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review report, which set forth a factual basis and medical rationale, made a prima facie showing of no medical necessity that the provider failed to rebut, so those causes of action were dismissed.
Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2010 NY Slip Op 50066(U)) Appellate Term, Second Department, January 12, 2010Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report, setting out a factual basis and medical rationale that the supplies were unnecessary, raised a triable issue defeating the provider's summary judgment motion on that claim.
Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52635(U)) Appellate Term, Second Department, December 23, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review reports setting forth a factual basis and medical rationale raised an issue of fact as to medical necessity, so the provider's motion should have been denied.
Staten Is. Advanced Surgical Supply v GEICO Ins. Co. (2009 NY Slip Op 52633(U)) Appellate Term, Second Department, December 23, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report, setting forth a factual basis and medical rationale that the equipment was unnecessary, raised a triable issue, but declined to search the record for the insurer.
Quality Rehab & P.T., P.C. v GEICO Ins. Co. (2009 NY Slip Op 52632(U)) Appellate Term, Second Department, December 23, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed IME reports setting forth a factual basis and medical rationale that the services were unnecessary raised an issue of fact, so the provider's motion should have been denied.
Crotona Hgts. Med., P.C. v GEICO Ins. Co. (2009 NY Slip Op 52466(U)) Appellate Term, Second Department, December 7, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itGranted the insurer summary judgment on two causes of action because its affirmed peer review set forth a factual basis and medical rationale for lack of medical necessity and was unrebutted.
Innovative Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52447(U)) Appellate Term, Second Department, December 1, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor's affidavit and peer review established lack of medical necessity, and the treating chiropractor's affidavit merely asserting necessity without supporting facts raised no triable issue.
AJS Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52446(U)) Appellate Term, Second Department, December 1, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractor's affidavit and peer review set forth a factual basis and medical rationale for lack of medical necessity, which was unrebutted, so the insurer won summary judgment.
Innovative Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 52321(U)) Appellate Term, Second Department, November 13, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report gave a factual basis and medical rationale, and the provider's chiropractor's affidavit, which did not meaningfully refer to it, failed to rebut the showing, so the complaint was dismissed.
Exclusive Med. Supply, Inc. v Mercury Ins. Group (2009 NY Slip Op 52273(U)) Appellate Term, Second Department, November 5, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld an affirmed peer review and a chiropractor's sworn peer review set forth a factual basis and medical rationale, and the provider submitted no rebutting evidence, so summary judgment went to the insurer.
Richmond Radiology, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52210(U)) Appellate Term, Second Department, October 23, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review, finding no substantiation of necessity in the records reviewed, raised a triable issue, so the provider's motion was properly denied, while declining to grant the insurer summary judgment.
Right Aid Diagnostic Medicine, P.C. v Geico Ins. Co. (2009 NY Slip Op 52122(U)) Appellate Term, Second Department, October 13, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's timely denial based on an affirmed peer review setting forth a factual basis and medical rationale raised a triable issue on medical necessity, denying the provider's motion but declining to search the record for the insurer.
Med-Tech Prods., Inc. v Geico Ins. Co. (2009 NY Slip Op 52111(U)) Appellate Term, Second Department, October 13, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review reports with a factual basis and medical rationale raised a triable issue as to medical necessity; treated the admissibility objection as waived and declined to search the record.
Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U)) Appellate Term, Second Department, July 9, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the examining physician's affirmed report gave a factual basis and medical rationale for finding the MRI unnecessary, and the provider failed to rebut it, so summary judgment for the insurer was affirmed.
Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) Leading case Appellate Term, Second Department, July 9, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review with the underlying records shifted the burden, and the provider's affidavit merely disagreeing without meaningfully referring to the peer review raised no triable issue.
Bronze Acupuncture, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51219(U)) Appellate Term, Second Department, June 12, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report and acupuncturist's affidavit established lack of medical necessity, and the treating acupuncturist's bare disagreement without supporting facts raised no triable issue.
Bath Med. Supply, Inc. v Country Wide Ins. Co. (2009 NY Slip Op 51145(U)) Appellate Term, Second Department, June 8, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report raised a triable issue of fact as to medical necessity of the supplies, so the provider's summary judgment motion was denied.
Vista Surgical Supplies, Inc. v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 51031(U)) Appellate Term, Second Department, May 22, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held, as an additional ground, that the apparently identical signatures on the affirmed peer reviews raised an issue under CPLR 2106, so the insurer's motion on lack of medical necessity had to be denied.
Cornell Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 29228) Appellate Term, Second Department, May 22, 2009Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Held the provider's physician's affirmation raised an issue of fact as to medical necessity, so the insurer's motion to dismiss those bills was properly denied.
A.B. Med. Servs., PLLC v Country-Wide Ins. Co. (2009 NY Slip Op 51016(U)) Appellate Term, Second Department, May 19, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the acupuncturist's unsworn peer reviews of no probative value, so they raised no triable issue and the acupuncture provider won summary judgment, while affirmed peer reviews defeated the motion on other providers' claims.
Bongiorno v State Farm Ins. Co. (2009 NY Slip Op 50860(U)) Appellate Term, Second Department, April 28, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report made a prima facie showing of lack of medical necessity, and because the provider filed no opposition the showing was unrebutted, entitling the insurer to summary judgment.
St. Vincent Med. Care, P.C. v Mercury Cas. Co. (2009 NY Slip Op 50810(U)) Appellate Term, Second Department, April 24, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME and peer review reports established lack of medical necessity, and the provider's rebuttal was inadmissible because its principal, a party, could not use a CPLR 2106 affirmation.
Vista Surgical Supplies, Inc. v GEICO Ins. Co. (2009 NY Slip Op 50739(U)) Appellate Term, Second Department, April 16, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established prima facie that the supplies were not medically necessary and the provider offered no rebuttal, so the insurer's cross motion was properly granted.
Dilon Med. Supply Corp. v Travelers Ins. Co. (2009 NY Slip Op 50737(U)) Appellate Term, Second Department, April 16, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal after trial because the credited testimony of the insurer's peer review doctor established lack of medical necessity for the supplies and the provider offered no rebuttal evidence.
Velen Med. Supply, Inc. v GEICO Ins. Co. (2009 NY Slip Op 50735(U)) Appellate Term, Second Department, April 16, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review raised a triable issue of medical necessity, so the provider's summary judgment was vacated; the facsimile-signature objection was waived because first raised on appeal.
Ortho-Med Surgical Supply, Inc. v Mercury Cas. Co. (2009 NY Slip Op 50731(U)) Appellate Term, Second Department, April 14, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed IME report made a prima facie showing that the supplies were not medically necessary and, the provider having failed to rebut it, affirmed summary judgment for the insurer.
Rogy Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50732(U)) Appellate Term, Second Department, April 14, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review report was not competent evidence because its stamped or electronic signature was not shown to have been placed by the reviewer or at his direction, so the insurer was not entitled to summary judgment.
Metropolitan Med. Supplies, LLC v Eveready Ins. Co. (2009 NY Slip Op 50586(U)) Appellate Term, Second Department, April 3, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review showed the claim was properly denied for lack of medical necessity, so the provider's summary judgment motion was denied.
PLP Acupuncture, P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50491(U)) Appellate Term, Second Department, March 17, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity, since the provider could not challenge the reliability of its own reports and reliance on other providers' reports did not defeat it, and the provider failed to rebut it.
Park Slope Med. & Surgical Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 50441(U)) Appellate Term, Second Department, March 12, 2009Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer made a prima facie showing through the peer review, but the provider's doctor's affidavit disagreeing and concluding the supplies were necessary raised an issue of fact, so the cross motion was denied.
Continental Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50234(U)) Appellate Term, Second Department, February 13, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME report established lack of medical necessity because the chiropractor's improper affirmation was waived by the provider's failure to object, and the provider's unsworn 'dictated but not read' report had no probative value as rebuttal.
AJS Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 50208(U)) Appellate Term, Second Department, February 9, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the chiropractic IME report with the chiropractor's affidavit was admissible and gave a factual basis and medical rationale, and the provider offered no evidence to refute it, so the complaint was dismissed.
Complete Orthopedic Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2009 NY Slip Op 29014) Appellate Term, Second Department, January 9, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established prima facie that the supplies were not medically necessary, and the proof was unrebutted, so the insurer's cross motion was granted.
Delta Diagnostic Radiology, P.C. v Progressive Casualty Insurance Company (2008 NY Slip Op 52450(U)) Appellate Term, Second Department, December 3, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its peer review reports and reviewer's affidavit gave a factual basis and medical rationale showing the MRIs were not medically necessary, and the provider offered no evidence in rebuttal.
A.B. Med. Servs., PLLC v Country-Wide Ins. Co. (2008 NY Slip Op 52651(U)) Appellate Term, Second Department, November 26, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the acupuncturist's unsworn peer reviews of no probative value, so they raised no triable issue and the acupuncture provider won summary judgment, while affirmed peer reviews defeated the motion on other providers' claims.
Avenue N Med., P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 52174(U)) Appellate Term, Second Department, October 31, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review established the claims were properly denied for lack of medical necessity, so denial of the provider's summary judgment motion was affirmed.
Alur Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51867(U)) Appellate Term, Second Department, September 10, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review established lack of medical necessity for the supplies and was unrebutted; the facsimile-signature objection was waived as raised first on appeal.
Careplus Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 28341) Appellate Term, Second Department, September 10, 2008Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer's affirmed peer review reports, submitted with its timely denials, raised a triable issue of fact as to medical necessity, so the provider's summary judgment motion was properly denied.
Ying E. Acupuncture, P.C. v Global Liberty Ins. (2008 NY Slip Op 51863(U)) Appellate Term, Second Department, September 3, 2008Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held an affirmed IME report with a factual basis and medical rationale raised a triable issue as to services after the IME, but not as to services rendered before the IME.
Midisland Med., PLLC v Allstate Ins. Co. (2008 NY Slip Op 51861(U)) Appellate Term, Second Department, September 3, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld one affirmed peer review lacked a factual basis because the reviewer cited insufficient documentation, but another set forth a sufficient factual basis and medical rationale to raise a triable issue on medical necessity.
Orthotic Surgical & Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51858(U)) Appellate Term, Second Department, September 2, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld the peer reviewer's affidavit, setting forth a factual basis and medical rationale, raised a triable issue as to medical necessity, so the provider's motion was denied, while declining to grant the insurer summary judgment.
Crossbridge Diagnostic Radiology, P.C. v Progressive Ins. Co. (2008 NY Slip Op 51761(U)) Appellate Term, Second Department, August 19, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review reports set forth a factual basis and medical rationale that the MRIs were not medically necessary, not merely a lack of documentation, and the provider did not rebut them.
Quality Health Prods., P.C. v Progressive Ins. Co. (2008 NY Slip Op 51757(U)) Appellate Term, Second Department, August 19, 2008Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the affirmed peer review report, which set forth a factual basis and medical rationale, raised a triable issue as to medical necessity of the supplies, defeating the provider's summary judgment motion on that claim.
NYC East-West Acupuncture, P.c. v Maryland Cas. Co. (2008 NY Slip Op 51762(U)) Appellate Term, Second Department, August 19, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed IME report established lack of medical necessity and, the provider not opposing the cross motion, was unrebutted, entitling the insurer to dismissal of those causes of action.
Mani Med., P.C. v Eveready Ins. Co. (2008 NY Slip Op 52697(U)) Appellate Term, Second Department, July 25, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports failed to raise a triable issue because the insurer conceded they bore stamped signatures with nothing showing they were affixed by or at the direction of the reviewing doctor.
Orthotic Surgical & Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51540(U)) Appellate Term, Second Department, July 10, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review report inadmissible because it bore a stamped facsimile signature not shown to be placed by or at the direction of the reviewer, so the insurer failed to raise a triable issue on medical necessity.
Eagle Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2008 NY Slip Op 51538(U)) Appellate Term, Second Department, July 10, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report established prima facie that the supplies on one claim were not medically necessary and, unrefuted by the provider, warranted dismissal, while the peer review on another claim failed to establish lack of necessity.
S.J. Pahng, M.D., P.C. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 51537(U)) Appellate Term, Second Department, July 10, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed the minimal trial award because the insurer's peer reviewer's deposition testimony established lack of medical necessity for the nerve testing and the provider offered no rebuttal evidence.
Radiology Today, P.C. v GEICO Ins. Co. (2008 NY Slip Op 28259) Appellate Term, Second Department, July 8, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to raise a triable issue on medical necessity because its peer review report bore a stamped facsimile signature not shown to have been placed by or at the direction of the reviewer, so it was inadmissible under CPLR 2106.
Mega Supplies Billing, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51418(U)) Appellate Term, Second Department, July 1, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its sworn papers, including an affirmed peer review report, established prima facie that the supplies were not medically necessary and the provider offered no rebuttal.
All Borough Group Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51417(U)) Appellate Term, Second Department, July 1, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed summary judgment for the insurer because its affirmed peer review report established prima facie that the supplies were not medically necessary and the provider left that showing unrebutted.
Alur Med. Supply, Inc. v Country-Wide Ins. Co. (2008 NY Slip Op 51234(U)) Appellate Term, Second Department, June 12, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's affirmed IME report did not establish prima facie that the medical supplies were unnecessary because it did not address the need for supplies, so its cross motion was denied.
Vista Surgical Supplies, Inc. v American Protection Ins. Co. (2008 NY Slip Op 51229(U)) Appellate Term, Second Department, June 12, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review established prima facie that the supplies were not medically necessary and, the provider presenting no refuting evidence, the insurer was entitled to summary judgment.
Eden Med., P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 51098(U)) Appellate Term, Second Department, May 27, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal because the insurer's affirmed peer review report established prima facie that the services were not medically necessary and the provider presented no evidence refuting it.
Med-Tech Prod., Inc. v Liberty Mut. Ins. Co. (2008 NY Slip Op 51469(U)) Appellate Term, Second Department, April 29, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review set forth a sufficient factual basis and medical rationale to raise an issue of fact as to medical necessity, so the provider's motion was properly denied.
A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50910(U)) Appellate Term, Second Department, April 25, 2008Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's opposition, including a peer review report, sufficed to raise an issue of fact on lack of medical necessity, so the provider's summary judgment motion was properly denied.
Boris Kleyman, P.C. v Kemper Ins. Co. (2008 NY Slip Op 50877(U)) Appellate Term, Second Department, April 24, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to raise a triable issue on medical necessity because the peer review reports it submitted were illegible, so the provider's motion should have been granted.
Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50535(U)) Appellate Term, Second Department, March 12, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's sworn papers, including detailed peer review reports, established prima facie that the MRIs were not medically necessary, and being unrebutted entitled the insurer to summary judgment.
Eagle Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50534(U)) Appellate Term, Second Department, March 12, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAffirmed dismissal because the insurer's affirmed peer review report established prima facie that the supplies were not medically necessary and the provider presented no evidence refuting it.
NY Comprehensive Med., P.C. v Maryland Cas. Co. (2008 NY Slip Op 50521(U)) Appellate Term, Second Department, March 10, 2008Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the provider's cross motion should have been denied because the denial form did not need to state a medical rationale and the provider conceded the conflicting affirmations on medical necessity raised an issue of fact.
Bath Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 50347(U)) Appellate Term, Second Department, February 26, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review and its chiropractor's affidavit established prima facie that the supplies were not medically necessary, and the provider failed to rebut it, so the complaint was dismissed.
Be Well Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 50346(U)) Appellate Term, Second Department, February 21, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's affirmed peer review established prima facie that the supplies were not medically necessary, and the provider offered no medical evidence in rebuttal, so the insurer was granted judgment on that claim.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U)) Appellate Term, Second Department, December 27, 2007Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's peer review report established prima facie that the MRIs were not medically necessary and, being unrebutted by the provider, entitled the insurer to summary judgment on its cross motion.
Dilon Med. Supply Corp. v New York Cent. Mut. Ins. Co. (2007 NY Slip Op 52454(U)) Appellate Term, Second Department, December 27, 2007Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the trial court erred in precluding the insurer's medical expert because he did not prepare the peer reviews; he was available for cross-examination and limited to the reports' basis, so a new trial was ordered.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2007 NY Slip Op 27371) Appellate Term, Second Department, September 14, 2007Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's papers raised a triable issue of fact on lack of medical necessity for the sessions denied on the basis of an IME, so the provider was not entitled to summary judgment on them.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) Appellate Term, Second Department, August 20, 2007Insurer's proof was enough to defeat the provider's motion but not to winHeld the denials based on affirmed peer reviews preserved the defense and the insurer's opposition demonstrated an issue of fact on lack of medical necessity, defeating the provider's cross motion.
Andrew Carothers, M.D., P.C. v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51613(U)) Appellate Term, Second Department, August 16, 2007Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's opposition, with denials based on peer reviews, demonstrated an issue of fact as to lack of medical necessity, so the provider's motion should have been denied.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U)) Leading case Appellate Term, Second Department, July 3, 2007Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the insurer's peer review report established prima facie that the MRIs were not medically necessary and, being unrebutted, entitled it to summary judgment granted on a search of the record.
I & B Surgical Supply v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 27159) Appellate Term, Second Department, April 25, 2007Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review made a prima facie showing that the supplies were not medically necessary, and the provider, whose untimely opposition could not be considered, raised no triable issue.
A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2007 NY Slip Op 50680(U)) Appellate Term, Second Department, March 28, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held two peer reviews finding services unnecessary for lack of sufficient information raised no triable issue absent a verification request, while one peer review with a factual basis and rationale raised a triable issue.
Support Billing & Mgt. Co. v Allstate Ins. Co. (2007 NY Slip Op 50496(U)) Appellate Term, Second Department, March 12, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review reports inadmissible because they bore only stamped facsimile signatures not shown to have been placed by the doctor, so no triable issue on medical necessity was raised and the provider won summary judgment.
Vista Surgical Supplies, Inc. v Travelers Ins. Co. (2006 NY Slip Op 52502(U)) Appellate Term, Second Department, December 15, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review reports bearing a stamped facsimile signature were not in admissible form under CPLR 2106, so the insurer failed to raise a triable issue on medical necessity.
Delta Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 52370(U)) Appellate Term, Second Department, December 8, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer, whose denial and affirmed peer review report fully set forth a lack of medical necessity, raised a triable issue defeating the provider's cross motion.
W.H.O. Acupuncture, P.C. v Eveready Ins. Co. (2006 NY Slip Op 52244(U)) Appellate Term, Second Department, November 8, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the provider not entitled to summary judgment because the insurer's opposition included the peer reviewer's affidavit incorporating a factually sufficient peer review report, raising an issue on medical necessity.
West Tremont Med. Diagnostic, P.C. v Geico Ins. Co. (2006 NY Slip Op 51871(U)) Leading case Appellate Term, Second Department, September 29, 2006Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the insurer's expert testimony established lack of medical necessity for the MRIs, shifting the burden to the provider, which offered no evidence, so judgment was directed for the insurer.
Delta Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51557(U)) Appellate Term, Second Department, July 26, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review reports set out factual bases and medical rationales, raising triable issues of fact as to medical necessity and defeating the provider's motion.
A.B. Med. Servs. PLLC v Peerless Ins. Co. (2006 NY Slip Op 26318) Appellate Term, Second Department, July 26, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the peer review inadequate to establish a factual basis and medical rationale for lack of medical necessity because the reviewer was not given the provider's narrative and follow-up reports.
Delta Diagnostic Radiology, P.C. v American Mfrs. Mut. Ins. Co. (2006 NY Slip Op 51439(U)) Appellate Term, Second Department, July 18, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer raised a triable issue by showing timely verification requests and timely denials based on lack of medical necessity set forth in detailed peer review reports.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51412(U)) Appellate Term, Second Department, July 12, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the peer review's factual basis and medical rationale raised a triable issue of medical necessity, and the reviewer's reference to unavailable records did not mean verification was required, so the supplier's motion was denied.
Psychological Practice, P.C. v Kemper Auto & Home Ins. Co. (2006 NY Slip Op 51289(U)) Appellate Term, Second Department, July 3, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the peer review annexed to the timely denial asserted sufficient facts and a medical rationale, so a trial was required and neither side was entitled to summary judgment.
Hempstead Turnpike Open Mri & Imaging v Progressive Ins. Co. (2006 NY Slip Op 51287(U)) Appellate Term, Second Department, July 3, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review, concluding a CAT scan of an area already imaged by MRI was unsupported by the records, set forth a factual basis and medical rationale sufficient to raise a triable issue, defeating the provider's motion.
Amol, Inc. v Travelers Ins. Co. (2006 NY Slip Op 51271(U)) Appellate Term, Second Department, June 28, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the insurer's lack-of-medical-necessity defense, based on a peer review report annexed to its timely denial, raised a triable issue defeating the provider's summary judgment motion.
Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51185(U)) Appellate Term, Second Department, June 8, 2006Insurer'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.
Lexington Acupuncture, P.C. v State Farm Ins. Co. (2006 NY Slip Op 26251) Appellate Term, Second Department, June 7, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the insurer's unsworn IME report inadmissible and therefore insufficient to defeat the provider's motion on medical necessity.
Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2006 NY Slip Op 51047(U)) Appellate Term, Second Department, June 2, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the peer review annexed to the timely denial set forth a factual basis and medical rationale that the equipment was unnecessary, raising a triable issue on that claim.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51336(U)) Appellate Term, Second Department, May 24, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's affirmed peer review report admissible despite referring to unaffirmed treating-doctor reports, so it raised a triable issue of medical necessity defeating the provider's summary judgment motion.
SZ Med. P.C. v Country-Wide Ins. Co. (2006 NY Slip Op 26194) Appellate Term, Second Department, May 17, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the unsworn nurse's peer review report lacked sufficient facts and a medical rationale, was inadmissible, and came from a reviewer not shown competent, so it did not establish lack of medical necessity.
Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co (2006 NYSlipOp 50491(U)) Appellate Term, Second Department, March 27, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the timely denial and affirmed peer review fully and explicitly set forth the reasons for the medical-necessity denial, raising a triable issue that defeated the provider's cross motion.
All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co. (2006 NY Slip Op 50318(U)) Appellate Term, Second Department, March 3, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review, which rested on lack of sufficient information without any verification request, lacked an adequate factual basis and medical rationale, so the defense failed and the provider won summary judgment.
Fair Price Med. Supply Corp. v ELRAC Inc. (2006 NY Slip Op 50859(U)) Appellate Term, Second Department, February 28, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the insurer's unsworn doctors' reports were insufficient to establish lack of medical necessity or rebut the provider's showing.
Ocean Diagnostic Imaging P.C. v Allstate Ins. Co. (2006 NY Slip Op 50140(U)) Appellate Term, Second Department, February 3, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer raised no triable issue on the MRIs' necessity because its unsworn peer review never addressed the provider's sworn doctor's report detailing why the MRIs were medically necessary.
Air Plus Surgical Supply, Inc. v Progressive Ins. Co. (2005 NY Slip Op 52088(U)) Appellate Term, Second Department, December 12, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the factually specific peer review, though enough to assert the defense in the denial, was unaffirmed and not in admissible form, so it could not defeat the supplier's summary judgment motion.
D.A.V. Chiropractic P.C. v GEICO Ins. (2005 NY Slip Op 51746(U)) Appellate Term, Second Department, October 21, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the unaffirmed peer reviews, which the provider itself submitted and relied on, contained a sufficient factual basis and medical rationale to raise a triable issue of medical necessity, so the provider's motion was denied.
Amaze Med. Supply Inc. v Hereford Ins. Co. (2005 NYSlipOp 51331(U)) Appellate Term, Second Department, August 11, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's peer reviews set forth a factual basis and medical rationale sufficient to raise a triable issue on the equipment's medical necessity, so the supplier's motion was properly denied.
A.B. Med. Servs. PLLC v Travelers Prop. Cas. Corp. (2005 NY Slip Op 51330(U)) Appellate Term, Second Department, August 11, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's peer reviews set forth a factual basis and medical rationale sufficient to raise a triable issue on medical necessity, so the providers' motion was properly denied.
Medwide Med. Supply Inc. v Country-Wide Ins. Co. (2005 NYSlipOp 51078(U)) Appellate Term, Second Department, July 7, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the unsworn nurse medical reviews were not competent evidence to defeat summary judgment, no excuse was offered, and they failed to state the nurse's training or experience, so the timely denied claims were awarded.
A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co. (2005 NYSlipOp 50650(U)) Appellate Term, Second Department, April 29, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to offer proof in admissible form raising a triable issue on its lack-of-medical-necessity defense, so the provider's motion should have been granted.
A.B. Med. Servs. PLLC v Integon Natl. Ins. Co. (2005 NYSlipOp 50643(U)) Appellate Term, Second Department, April 29, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed peer review raised a triable issue on the first test because no interim notes preceded it, but granted the provider judgment on the second test because the peer review's stated basis was factually wrong.
South Queens Imaging P.C. v Nationwide Mut. Ins. Co. (2005 NYSlipOp 50608(U)) Appellate Term, Second Department, April 22, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn IME and peer review reports were not competent proof in admissible form, with no excuse offered, and so did not defeat the provider's summary judgment motion.
A.B. Med. Servs. PLLC v Electric Ins. Co. (2005 NYSlipOp 50542(U)) Appellate Term, Second Department, April 13, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn acupuncturist peer review report inadmissible and therefore insufficient to raise a triable issue on medical necessity, so the provider was granted summary judgment on those claims.
A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (2005 NYSlipOp 50453(U)) Appellate Term, Second Department, March 31, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's peer review report was unsworn and therefore not in admissible form, so it did not warrant denial of the provider's summary judgment motion.
Amaze Med. Supply Inc. v Travelers Prop. Cas. Corp. (2005 NY Slip Op 50452(U)) Appellate Term, Second Department, March 31, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the timely peer-review-based denial, finding no substantiation of necessity in the records reviewed, raised a triable issue on medical necessity, and the insurer need not have sought further verification.
Amaze Med. Supply Inc. v GEICO Ins. (2005 NYSlipOp 51053(U)) Appellate Term, Second Department, February 17, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn peer review report was not in admissible form and so was insufficient to defeat the supplier's summary judgment motion despite the timely denial.
A.B. Med. Servs. PLLC v American Mfrs. Mut. Ins. Co. (2005 NY Slip Op 50114(U)) Appellate Term, Second Department, February 2, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held a peer review finding no medical necessity only because the reviewer lacked sufficient information raised no triable issue absent verification requests, so the insurer was precluded from the defense and the provider won summary judgment.
Triboro Chiropractic v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50110(U)) Appellate Term, Second Department, February 2, 2005Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held the pre-claim IME nonappearance rebutted the presumption of medical necessity, defeating the provider's motion on the timely denied claims absent independent proof of necessity.
A.B. Med. Servs. PLLC v Motor Veh. Acc. Indem. Corp. (2005 NY Slip Op 50088(U)) Appellate Term, Second Department, February 1, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held, as an alternative to preclusion, that the unsworn peer review report was not in admissible form and so could not defeat the provider's summary judgment motion.
Amaze Med. Supply Inc. v Lumbermens Mut. Cas. Co. (2005 NY Slip Op 50084(U)) Appellate Term, Second Department, January 27, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's unsworn peer review report was not in admissible form and so could not defeat the provider's summary judgment motion.
Amaze Med. Supply, Inc. v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 51110(U)) Appellate Term, Second Department, October 1, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the defaulting insurer showed no meritorious lack-of-medical-necessity defense because it submitted no affidavit from anyone with personal knowledge of the facts.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 50833(U)) Appellate Term, Second Department, July 21, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the peer review underlying the one timely denied claim was a chiropractor's affirmation, which is not competent evidence under CPLR 2106, so it could not defeat summary judgment.
A.B. Med. Servs., Pllc v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50550(U)) Appellate Term, Second Department, May 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held that unaffirmed medical reports, though enough to support a timely denial, were not proof in admissible form and failed to raise a triable issue of medical necessity against the providers' motion.
A.B. Med. Servs. v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50507(U)) Appellate Term, Second Department, May 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held that unaffirmed medical reports, though enough to support a timely denial, were not proof in admissible form and failed to raise a triable issue of medical necessity against the providers' motion.
A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 24194) Appellate Term, Second Department, May 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer, which opposed with only its attorney's affirmation and no sworn peer review, failed to raise a triable issue of medical necessity despite its timely denials.
Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 50263(U)) Appellate Term, Second Department, April 9, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the insurer showed no meritorious defense for vacating its default because the peer review behind its denial was conclusory and lacked a medical rationale.
S & M Supply v Kemper Auto & Home Ins. Co. (2004 NY Slip Op 50217(U)) Appellate Term, Second Department, March 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Granted the provider summary judgment because the insurer opposed with only part of an unsworn letter from its medical expert that set forth no factual basis or medical rationale for finding the supplies unnecessary.
Triboro Chiropractic & Acupuncture v Elec. Ins. Co. (2004 NY Slip Op 50215(U)) Appellate Term, Second Department, March 26, 2004Insurer's proof was enough to defeat the provider's motion but not to winAffirmed denial of the provider's partial summary judgment motion because the insurer's timely denials rested on a peer review and IME that set forth a sufficient factual foundation and medical rationale, raising triable issues of medical necessity.
S & M Supply v Kemper Auto & Home Ins. Co. (2004 NY Slip Op 50209(U)) Appellate Term, Second Department, March 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Granted the provider summary judgment because the insurer opposed with only part of an unsworn letter from its medical expert that set forth no factual basis or medical rationale for finding the supplies unnecessary.
Abraham v Country-Wide Ins. Co. (2004 NY Slip Op 50388(U)) Appellate Term, Second Department, February 10, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held unsworn nurses' file reviews were incompetent, with no shown qualifications to give medical opinions, and did not raise a triable issue of medical necessity, so the provider got partial summary judgment.
Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U)) Appellate Term, Second Department, December 22, 2003Insurer's proof was enough to defeat the provider's motion but not to winAffirmed denial of the provider's summary judgment motion because the insurer's affirmed file-based peer review set forth a factual basis and medical rationale sufficient to create a triable issue of medical necessity.

Trial courts in the First Department (10 decisions)

New York Ctr. for Specialty Surgery v State Farm Ins. Co. (2021 NY Slip Op 50314(U)) Civil Court of the City of New York, Bronx County, April 14, 2021Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer's chiropractor failed to show the MUA procedures were unnecessary because his pre-MUA standards lacked support in the protocols and the record showed each procedure was justified.
Allstate Ins. Co. v DHD Med., P.C. (2021 NY Slip Op 50011(U)) Supreme Court, New York County, January 8, 2021Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that the insurer's IME report and the provider's treatment records with a physician's affirmation were conflicting medical evidence raising a question of fact on necessity, so neither side got summary judgment.
Harvey Family Chiro PT & Acup, PLLC v Ameriprise Ins. Co. (2020 NY Slip Op 20136) Civil Court of the City of New York, Bronx County, June 15, 2020Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer's IME reports made a prima facie showing, but the treating chiropractor's affidavit reviewing the assignor's records rebutted it and raised a triable issue, so the insurer's motion was denied.
NYC Sports Acupuncture PC v MVAIC (2020 NY Slip Op 50393(U)) Civil Court, New York County, April 7, 2020Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn IME report set forth a factual basis and medical rationale for no further treatment, and the provider submitted no doctor's affidavit to rebut it, so later services were dismissed.
Eagle Surgical Supply, Inc. v Geico Ins. Co. (2011 NY Slip Op 52142(U)) Civil Court of the City of New York, Bronx County, November 3, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's proposed medical testimony on lack of necessity inadmissible because it had no HIPAA authorization or Privacy Rule exception, leaving no evidence against the stipulated prima facie case, so judgment went to the provider.
Ray Presutto, L.M.T., P.C. v Travelers Ins. Co. (2007 NY Slip Op 52095(U)) Civil Court of the City of New York, New York County, October 29, 2007Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed IME report based on objective testing established lack of medical necessity, and the massage therapist's terse conclusory affidavit failed to raise a triable issue, so the complaints were dismissed.
Tahir v Progressive Cas. Ins. Co. (2006 NY Slip Op 26149) Civil Court, New York County, April 18, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed to prove lack of medical necessity for the sensory nerve testing because its expert did not address the patients' medical status or review each claim individually, and Medicare noncoverage was no defense.
Chiropractic Neurodiagnosis, PC v Travelers Indem. Co. (2006 NY Slip Op 50257(U)) Civil Court of the City of New York, New York County, February 5, 2006Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Rejected the provider's argument that it deserved judgment regardless of timely denial, holding the insurer's sworn peer review report was in admissible form, while declining to decide whether it established lack of medical necessity.

Show all 10 decisions

Precision Diagnostic Imaging, P.C. v Travelers Ins. Co. (2005 NY Slip Op 25180) Civil Court, New York County, May 12, 2005Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review, explaining that MRIs were unnecessary absent post-pregnancy x-rays and a neurological exam, shifted the burden, and the radiology provider submitted no medical evidence, so the insurer won summary judgment.
Healing Hands Chiropractic, P.C. v Nationwide Assur. Co. (2004 NY Slip Op 24472) Civil Court of the City of New York, New York County, December 1, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's medical-necessity denial unsupported by competent evidence because it relied only on prior arbitration decisions about the testing rather than a peer review or examination, so it raised no triable issue.

Trial courts in the Second Department (87 decisions)

Syed Asim Maqsood Med. PC v MVAIC (2026 NY Slip Op 51401(U)) Civil Court of the City of New York, Kings County, August 18, 2026Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held the insurer made its prima facie showing on six bills, but the provider's rebuttal physician affidavit raised a question of fact on medical necessity requiring trial.
Big Apple Delivery Supply Corp. v Plymouth Rock Assur. Corp. of N.Y. (2025 NY Slip Op 50315(U)) Civil Court of the City of New York, Richmond County, March 11, 2025Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the electronically signed peer review reports were properly subscribed and affirmed and admissible, established lack of medical necessity for the supplies, and were not rebutted by any provider affirmation, so the complaint was dismissed.
Longevity Med. Supply Inc v Travelers Ins. Co. (2022 NY Slip Op 51285(U)) Civil Court of the City of New York, Kings County, November 29, 2022Insurer's proof established lack of medical necessity and the provider failed to rebut itDismissed the complaint after trial because the insurer's credible peer-review expert gave a factual basis and medical rationale that the supplies were unnecessary and the provider called no witnesses in rebuttal.
Top Choice Pharm. Corp. v Merchants Mut. Ins. Co. (2022 NY Slip Op 50867(U)) Civil Court of the City of New York, Queens County, September 14, 2022Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer reviewer's affirmation conclusory because it questioned the advisability of the prescribed lidocaine ointment without stating the treatment was unnecessary, so the insurer failed to establish lack of medical necessity.
MK Healthcare Med. PC v Travelers Ins. Co. (2022 NY Slip Op 50824(U)) Civil Court of the City of New York, Richmond County, August 25, 2022Insurer's proof established lack of medical necessity and the provider failed to rebut itEntered judgment for the insurer after trial because its credible peer reviewer showed a factual basis and medical rationale that the EMG and nerve studies were unnecessary, and the provider offered no witness or rebuttal evidence.
James J Kim, L, AC, PC v Allstate Ins Co (2022 NY Slip Op 50700(U)) Civil Court of the City of New York, Kings County, August 1, 2022Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held after trial that the pre-treatment IME shifted the burden, but the acupuncturist's credible testimony of evaluations before each session proved by a preponderance that the post-IME treatment was medically necessary.
SB Chiropractic, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50316(U)) Civil Court of the City of New York, Kings County, April 20, 2022Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the detailed IME reports rebutted the presumption of medical necessity for post-IME treatment, and the owner's vague, conclusory affidavit, which did not describe the assignor's condition, failed to show necessity.
Optimum Health Acupuncture, P.C. v Integon Natl. Ins. Co. (2022 NY Slip Op 50068(U)) District Court of Suffolk County, Fourth District, January 5, 2022Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the IME and peer review reports went unrefuted because the provider's claimed rebuttal affidavit from its acupuncturist was not actually attached to its papers.

Show all 87 decisions

Heavenly Points Acupuncture v Integon Natl. Ins. Co. (2021 NY Slip Op 50895(U)) Civil Court of the City of New York, Queens County, September 17, 2021Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the sworn peer review and examination report, which found normal range of motion and normal findings, established lack of medical necessity; the provider's affidavit was conclusory and did not meaningfully discuss that report, so the insurer won summary judgment.
Medalliance Med. Health Servs. v Travelers Prop. Cas. Ins. Co. (2021 NY Slip Op 50737(U)) District Court of Suffolk County, Fourth District, June 30, 2021Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held that the peer review/IME report and the treating chiropractor's rebuttal affidavit disputing its findings presented conflicting medical opinions raising triable issues on medical necessity, so the insurer's motion was denied.
Accelerated Chiropractic Care P.C. v Progressive Ins. (2017 NY Slip Op 51967(U)) Civil Court of the City of New York, Kings County, December 13, 2017Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the insurer's peer reviewer did not show manipulation under anesthesia was inconsistent with generally accepted practice; conflicting expert opinions showed only a difference in professional judgment, so the insurer failed its burden.
Professional Chiropractic Care, P.C. v 21st Century Ins. Co. (2017 NY Slip Op 27380) District Court of Suffolk County, Third District, November 27, 2017Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Held that conflicting detailed affidavits of qualified professionals on both sides raised factual issues as to medical necessity, so the insurer's summary judgment motion on that ground was denied.
Village Chiropractic v Geico Ins. Co. (2015 NY Slip Op 51189(U)) District Court of Nassau County, First District, August 17, 2015Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld three affirmed IME reports established lack of medical necessity after the cut-off date, and the chiropractor-owner's affidavit did not refute them, so the insurer got partial summary judgment.
Forest Rehabilitation Medicine PC v Allstate Ins. Co. (2014 NY Slip Op 24160) Civil Court of the City of New York, Richmond County, June 24, 2014Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After a bench trial, held the insurer's expert testimony, though it had a factual basis and rationale, insufficient to establish lack of medical necessity for scrambler pain therapy, which rested mainly on cost, and found the therapy medically necessary.
Boulevard Multispec Med., P.C. v Tri-State Consumer Ins. Co. (2014 NY Slip Op 24080) District Court of Nassau County, First District, March 26, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial) (also decides)Held that, even assuming the orthopedic IME report met the insurer's burden, the provider's physician affirmation supplied a factual basis and medical rationale, so conflicting expert opinions raised triable issues.
All-In-One Med. Care, P.C. v Government Empls. Ins. Co. (2014 NY Slip Op 24070) District Court of Nassau County, First District, March 13, 2014Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)After trial, held the IME doctor's credited testimony shifted the burden, but the treating doctor's admitted post-IME records, despite an adverse inference from not calling him, proved the post-IME physical therapy medically necessary.
Atlantic Radiology Imaging, P.C. v GEICO (2013 NY Slip Op 52256(U)) Civil Court of the City of New York, Kings County, December 18, 2013Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingRuled before trial that a substitute peer doctor could testify on lack of medical necessity and rely on the underlying medical records, which were not offered for their truth, so the defense could proceed to trial.
Forest Rehabilitation Medicine PC v Geico Ins. Co. (2013 NY Slip Op 50340(U)) Civil Court of the City of New York, Richmond County, February 27, 2013Insurer's proof established lack of medical necessity and the provider failed to rebut itDismissed after trial because the insurer's expert testified that the electromagnetic therapy was not accepted in the medical community and the provider, given the chance, offered no independent evidence of its acceptance or benefit.
Dugo v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 52375(U)) Civil Court of the City of New York, Richmond County, December 26, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Found in the alternative that the insurer failed to prove lack of necessity of the manipulation under anesthesia because it never gave its peer reviewer the treating chiropractor's narrative and notes, even after he requested them.
Willets Point Chiropractic P.C. v Allstate Ins. (2012 NY Slip Op 51614(U)) Civil Court of the City of New York, Richmond County, August 16, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)After trial, credited the insurer's chiropractic examiner's testimony that further chiropractic treatment, including the later manipulation under anesthesia, was unnecessary, and found the treating chiropractor's testimony insufficient to prove necessity, so the claims were dismissed.
Bajaj v GEICO (2012 NY Slip Op 51106(U)) District Court of Nassau County, First District, June 18, 2012Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Held a substitute expert could testify without the peer review in evidence and gave a facially sufficient rationale, but the treating physician's credible testimony rebutted it, so the EMG/NCV tests were found medically necessary.
Total Equip. LLC v State Farm Fire & Cas. Co. (2012 NY Slip Op 22038) District Court of Nassau County, First District, February 22, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the affirmed peer review set forth a sufficient factual basis and medical rationale, and a nontreating doctor's rebuttal relying on records not submitted was conclusory and raised no triable issue.
All Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 50138(U)) Civil Court of the City of New York, Kings County, January 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the stipulated peer review set forth a sufficient factual basis and medical rationale for the lack of necessity of the psychological testing, and the provider offered no rebuttal, so judgment went to the insurer.
All Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 50137(U)) Civil Court of the City of New York, Kings County, January 31, 2012Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the unrebutted peer review established lack of necessity for four tests, record review and explanation of results, but not for two tests the report never discussed.
All County, LLC v Tri-State Consumer Ins. Co. (2012 NY Slip Op 50119(U)) District Court of Nassau County, First District, January 23, 2012Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Denied the insurer's motion because the orthopedic IME report never examined or addressed the thoracic spine, did not identify who ordered the MRI or when, and so gave no factual basis or medical rationale.
Total Equip., LLC v Praetorian Ins. Co. (2011 NY Slip Op 21398) District Court of Nassau County, First District, November 9, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Denied the insurer's motion pending discovery and found the peer review unable to support summary judgment because the reviewer was not shown qualified as an expert and relied on hearsay records not in evidence.
Kraft v State Farm Mut. Auto. Ins. Co. (2011 NY Slip Op 21413) Civil Court of the City of New York, Queens County, October 6, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer's chiropractic expert failed to rebut the presumption of medical necessity of manipulation under anesthesia, because his asserted prerequisites lacked support and the records showed months of conservative care without improvement.
Novacare Med. P.C. v Travelers Prop. Cas. Ins. Co. (2011 NY Slip Op 50500(U)) District Court of Nassau County, Second District, April 1, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review insufficient to establish lack of medical necessity because it rested on conclusory assumptions contradicted by the treating records documenting persistent radicular symptoms, so the provider needed no opposing expert proof.
Consolidated Imaging P.C. (Rafailova) v Travelers Indem. Co. (2011 NY Slip Op 50159(U)) Civil Court of the City of New York, Richmond County, January 27, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed to prove the MRI unnecessary because its internist peer reviewer stated only a bare conclusion without identifying the generally accepted practice the referring physician breached, and her report contained unexplained errors.
A-Quality Med. Supply v GEICO Gen. Ins. Co. (2010 NY Slip Op 20502) Civil Court of the City of New York, Kings County, December 7, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the unsigned, unnotarized or undated peer reviews inadmissible even where the author testified, so the insurer failed to establish its lack of medical necessity defense.
Vladenn Med. Supply Corp. v GEICO (2010 NY Slip Op 51994(U)) Civil Court of the City of New York, Queens County, November 16, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld at trial that the substitute chiropractor's opinion, based on the assignor's records as a hypothetical premise, was admissible and established that the lumbosacral orthosis was not medically necessary, the provider calling no rebuttal witness.
Amato v State Farm Ins. Co. (2010 NY Slip Op 20431) District Court of Nassau County, First District, October 13, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed to prove a factual basis or medical rationale for denying post-IME chiropractic treatment because its IME doctor never reviewed records of that later treatment or knew the claimant's condition then.
Chiro Care Chiropractic Assoc. v GEICO Gen. Ins. Co. (2010 NY Slip Op 20404) District Court of Nassau County, Second District, September 24, 2010Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingDenied the provider's motion to preclude the insurer's internist expert, holding his proven familiarity with electrodiagnostic testing standards made his opinion admissible despite the chiropractic referral, with weight reserved for trial.
Elmont Open MRI & Diagnostic Radiology, PC v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 51588(U)) District Court of Nassau County, Second District, August 31, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed to prove lack of medical necessity because its chiropractor's peer review lacked a credible factual and medical basis and ignored the neurologist's and orthopedist's reliance on the MRIs.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins Co. (2010 NY Slip Op 51090(U)) District Court of Nassau County, Second District, June 4, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review, though sworn and stating a rationale, did not establish entitlement to judgment because it ignored the treating doctor's stated basis for the MRI and its positive findings.
Beal-Medea Prods., Inc. v GEICO Gen. Ins. Co. (2010 NY Slip Op 50800(U)) Civil Court of the City of New York, Kings County, May 6, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held at trial that the insurer failed to establish a factual basis and medical rationale because its substitute peer doctor's testimony was stricken for failure to establish the reliability of the out-of-court records he relied on.
IAV Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 50433(U)) Civil Court of the City of New York, Richmond County, March 15, 2010Insurer's proof established lack of medical necessity and the provider failed to rebut itAt trial, admitted the insurer's substitute expert's testimony based on another doctor's peer review though the reports were excluded, found him wholly credible, and held the provider offered no rebuttal expert, so judgment went to the insurer.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 50202(U)) District Court of Nassau County, Second District, January 27, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the insurer failed its burden because, although the MRIs were recommended prematurely, it offered no records of the claimant's condition when the tests were performed weeks later, so the presumption of necessity stood.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50053(U)) District Court of Nassau County, First District, January 6, 2010Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the neurologist peer reviewer and testifying re-peer doctor were not shown familiar with chiropractic standards for ordering MRIs, so their opinions could not rebut the presumption of medical necessity.
Popular Imaging, P.C. v State Farm Ins. Co. (2009 NY Slip Op 52355(U)) Civil Court of the City of New York, Richmond County, November 5, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itAfter trial, held the insurer's expert could rely on the referring physician's records and credited his testimony that the lumbar MRI was unnecessary; the provider offered no rebuttal evidence, so judgment went to the insurer.
Jesa Med. Supply, Inc. v GEICO Ins. Co. (2009 NY Slip Op 29386) Civil Court of the City of New York, Kings County, September 22, 2009Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer review admissible despite its stamped signature because the doctor's affirmation acknowledged applying it, and as the provider raised no issue of fact the $780 supply claim was dismissed.
Lenox Hill Radiology & MIA, P.C. v Global Liberty Ins. Co. of N.Y. (2009 NY Slip Op 51620(U)) Civil Court of the City of New York, Richmond County, July 6, 2009Insurer's proof was enough to defeat the provider's motion but not to win (also decides)Held that the insurer's timely denial, supported by a sufficient peer review report, left medical necessity for trial.
Millennium Radiology, P.C. v New York Cent. Mut. Fire Ins. Co.(2009 NY Slip Op 50877(U)) Civil Court of the City of New York, Richmond County, April 30, 2009Insurer's proof was enough to defeat the provider's motion but not to winHeld the sworn peer review, though bare-bones, gave enough rationale to raise an issue of fact defeating the provider's motion, but standing alone did not establish lack of necessity, so the insurer's cross motion was denied despite no rebuttal.
Elmont Open MRI & Diagnostic Radiology P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50693(U)) District Court of Nassau County, First District, April 6, 2009Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review reports inadequate because the reviewer was not qualified as an expert, stated no generally accepted practice or departure from it, and adopted an unproduced textbook opinion.
A.B. Med. Servs. PLLC v GEICO Gen. Ins. Co. (2008 NY Slip Op 52641(U)) Nassau District Court, November 24, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut it (also decides)Granted the insurer judgment on the one claim fully denied on a peer review because the provider submitted no medical evidence in reply.
A Plus Med., P.C. v Government Empls. Ins. Co. (2008 NY Slip Op 28381) Civil Court of the City of New York, Kings County, September 25, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer's peer reviewer, never qualified as an expert and conceding the MRI could help rule out nerve injury, did not establish lack of medical necessity, so the burden never shifted back.
Complete Med. Care Servs. of NY, P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 28324) Civil Court of the City of New York, Queens County, August 22, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the insurer failed its burden because its own expert conceded the EMG/NCV testing was medically necessary as prescribed, and allegedly incomplete performance of a necessary test does not make it medically unnecessary.
Andrew Carothers, M.D., P.C. v GEICO Indem. Co. (2008 NY Slip Op 51775(U)) Civil Court of the City of New York, Kings County, August 20, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the insurer's credited orthopedic expert showed the cervical MRI deviated from accepted standards for soft-tissue injuries, bias claims did not discredit him, and the provider offered no rebuttal evidence beyond cross-examination.
CityWide Social Work & Psychological Servs., PLLC v Allstate Ins. Co. (2008 NY Slip Op 51601(U)) District Court of Nassau County, Third District, July 1, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itAfter a trial limited to medical necessity, credited the insurer's expert testimony that the early psychological evaluation and testing deviated from accepted standards, and found the provider, which called no witnesses, failed to rebut it.
Velen Med. Supply Inc. v Travelers Ins. Co. (2008 NY Slip Op 28252) Civil Court of the City of New York, Queens County, June 13, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld the peer reviewer's trial testimony admissible though the underlying medical records were not in evidence, since the provider cannot challenge its own records' reliability, and found lack of necessity established because the provider offered no rebuttal evidence.
Carle Place Chiropractic v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51065(U)) District Court of Nassau County, First District, May 29, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held, as an alternative ground, that the insurer's IME report was conclusory and omitted any accepted professional standard and departure from it, and that the treating chiropractor's conflicting affidavit at least raised an issue of fact.
Andrew Carothers, M.D., P.C. v GEICO Indem. Co. (2008 NY Slip Op 50456(U)) Civil Court of the City of New York, Kings County, March 10, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the peer review and the provider's own records were admissible and the insurer's expert gave a factual basis and medical rationale for finding the early MRIs unnecessary, which the provider, calling no witnesses, failed to refute.
Cambridge Med., P.C. v Government Empls. Ins. Co. (2008 NY Slip Op 50435(U)) Civil Court of the City of New York, Richmond County, March 5, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the insurer's peer reviewer's testimony failed to establish lack of medical necessity for the EMG/NCV because it identified no generally accepted standard the provider departed from and was contradicted by his own concessions.
A.M. Med. Servs., P.C. v Deerbrook Ins. Co. (2008 NY Slip Op 50368(U)) Civil Court of the City of New York, Kings County, February 25, 2008Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the insurer's two experts' detailed, unrebutted testimony established that the EMG/NCV studies were not medically necessary, and the provider, calling no witnesses, failed to carry its shifted burden.
American Chinese Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 50205(U)) Civil Court of the City of New York, Richmond County, February 6, 2008Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the IME doctor's conclusory testimony failed prima facie to prove the acupuncture unnecessary because he stated no generally accepted standard or departure from it and did not address why acupuncture could not relieve the claimant's pain.
Acupuncture Prima Care, P.C. v State Farm Mut. Auto Ins. Co. (2007 NY Slip Op 52273(U)) District Court of Nassau County, First District, December 3, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held the acupuncturist's IME opinion conclusory and insufficient for a prima facie showing because it did not address accepted professional standards, the examiner's qualifications for the examinations, or objective tests performed.
Kings Highway Diagnostic Imaging, P.C. v Autoone Ins. Co. (2007 NY Slip Op 52253(U)) Civil Court of the City of New York, Kings County, November 27, 2007Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)Found the insurer's examining chiropractor showed the MRIs were not medically necessary, but the provider's neurologist rebutted it by testifying that complaints, age and positive objective tests made the MRIs necessary.
All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co. (2007 NY Slip Op 27458) Civil Court of the City of New York, Kings County, November 6, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held in the alternative after trial that the insurer's peer reviewer failed to prove the equipment unnecessary, because he conceded it was not against accepted medical protocol and said only he would not have recommended it.
Williamsbridge Radiology & Open Imaging v Travelers Indem. Co. (2007 NY Slip Op 50224(U)) Civil Court of the City of New York, Kings County, January 5, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed its burden because its peer reviewer's opinion was conclusory, did not address generally accepted practice, and rested on incomplete records without examining the patient.
Delta Med. Supplies, Inc. v NY Cent. Mut. Ins. Co. (2007 NY Slip Op 50241(U)) Civil Court of the City of New York, Kings County, January 3, 2007Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed its burden because its expert, who had never prescribed the supplies, offered no factual basis that the prescription deviated from accepted medical practice, so the burden never shifted.
Bajaj v Progressive Ins. Co. (2006 NY Slip Op 52387(U)) Civil Court of the City of New York, Queens County, November 20, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the peer reviewer's deposition opinion was inadmissible because it rested on unauthenticated records not in evidence, and in any event was conclusory and lacked a factual basis and medical rationale, so the insurer failed its burden.
Andrew Carothers, M.D., P.C. v Travelers Ins. Co. (2006 NY Slip Op 52328(U)) Civil Court of the City of New York, Kings County, November 14, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed its burden on lack of medical necessity because it called no witness and could not rely on the peer review admitted with its denial only to show timely receipt and denial.
Andrew Carothers, M.D., P.C. v Travelers Ins. Co. (2006 NY Slip Op 52154(U)) Civil Court of the City of New York, Kings County, November 2, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Held at trial that the insurer, offering no testimony or documents and relying only on cross-examination of the billing witness, failed to rebut the presumption of medical necessity attached to the claim forms.
Queensboro Med. Rehab, P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51936(U)) Civil Court of the City of New York, Kings County, October 12, 2006Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's admissible peer review raised a material issue of fact on medical necessity but did not rebut the presumption of necessity enough to entitle it to summary judgment, so both motions failed on those claims.
SK Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 26227) Civil Court of the City of New York, Richmond County, June 9, 2006Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld a substitute peer expert limited to the original reviewer's reports could testify, credited his testimony that the electrodiagnostic testing was unnecessary, and dismissed because the provider called no rebuttal witness.
Roberts Physical Therapy, P.C. v State Farm Mut. Auto Ins. Co. (2006 NY Slip Op 52565(U)) Civil Court of the City of New York, Kings County, May 30, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Treated the 'more than normally expected per visit' denial as a medical-necessity defense and held it failed: unpreserved without a supporting peer review or IME and, in any event, because the insurer offered no expert or documents at trial.
Expo Med. Supplies, Inc. v Clarendon Ins. Co. (2006 NY Slip Op 50892(U)) Civil Court of the City of New York, Kings County, May 16, 2006Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that the peer reviewer's testimony and reports, supported by cited medical literature, proved the supplies unnecessary or duplicative, and the treating chiropractor's report did not explain why they were prescribed, so the provider failed to rebut.
Tsai Chao v Country-Wide Ins. Co. (2006 NY Slip Op 50794(U)) Nassau District Court, May 3, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to raise a triable issue on lack of medical necessity because it submitted only an attorney's affirmation and no sworn peer review report.
A.R. Med. Art, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 50260(U)) Civil Court, Kings County, February 27, 2006Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer's expert, who deemed EMG/NCV tests unnecessary absent a diagnostic dilemma, failed to show the tests inconsistent with generally accepted practice, given the treating doctor's letter explaining their diagnostic purpose.
Stand-Up MRI of Bronx v General Assur. Ins. (2005 NY Slip Op 25453) District Court of Suffolk County, Second District, October 24, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Found the insurer's peer reviewer's trial testimony insufficient to establish by a preponderance that the MRIs were not medically necessary, though the case was dismissed on another ground.
Foster Diagnostic Imaging, P.C. v General Assur. Co. (2005 NY Slip Op 25431) Civil Court, Kings County, October 17, 2005Insurer's proof established lack of medical necessity and the provider failed to rebut itHeld after trial that once the no-show negated the presumption of necessity, the providers bore the burden and failed it: a bare referral, unconnected MRI findings and a conclusory necessity letter proved nothing.
Bedford Park Med. Practice P.C. v American Tr. Ins. Co. (2005 NY Slip Op 51282(U)) Civil Court of the City of New York, Kings County, August 12, 2005Insurer's proof was enough to defeat the provider's motion but not to winHeld the affirmed IME report had enough factual basis and medical rationale to raise a triable issue defeating the provider's motion, but not to establish lack of necessity prima facie, since it omitted the objective tests and the MRI finding's significance.
Citywide Social Work & Psychological Servs., P.L.L.C. v Allstate Ins. Co. (2005 NY Slip Op 51283(U)) Civil Court of the City of New York, Kings County, August 11, 2005Insurer's proof established lack of medical necessity and the provider failed to rebut itAfter trial, credited the insurer's psychologist that no comprehensive intake was done so the testing and reporting were unnecessary and the provider failed to rebut, but found the insurer failed its burden on the records review.
Omega Diagnostic Imaging, P.C. v State Farm Mut. Auto Ins. Co. (2005 NY Slip Op 25200) Civil Court of the City of New York, Kings County, May 23, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held a knee MRI was not unnecessary merely because a chiropractor prescribed it, since the insurer's expert conceded chiropractors use such MRIs and offered no evidence it was of no diagnostic assistance.
A.B. Med. Servs. P.L.L.C. v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50662(U)) Civil Court of the City of New York, Kings County, April 29, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial the insurer did not sustain its burden: its peer reviewer's opinion lacked support in generally accepted practice, and the treating neurologist's testimony justified the electrodiagnostic testing.
Sunnyside Plus, Inc. v Allstate Ins. Co. (2005 NY Slip Op 25110) Civil Court of the City of New York, Queens County, March 21, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held at trial that the peer reviewer could not give an opinion because the treating and radiology reports he relied on were neither in evidence nor shown reliable, so the insurer failed to prove lack of medical necessity.
Nir v Allstate Ins. Co. (2005 NY Slip Op 25090) Civil Court of the City of New York, Kings County, February 28, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held at trial that the insurer bore the burden on medical necessity and failed it, because its peer reviewer cited no medical standard and could not explain the positive test findings, and the provider's expert rebutted him.
Ocean Diagnostic Imaging P.C. v American Protection Ins. Co. (2005 NY Slip Op 50273(U)) Civil Court of the City of New York, Kings County, February 9, 2005Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the peer review was neither sworn nor affirmed, despite counsel's representation, and so was inadmissible and could not be used to oppose the provider's summary judgment motion.
Ultimate Med. Supplies v Lancer Ins. Co. (2004 NY Slip Op 51860(U)) Civil Court, Kings County, December 17, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer's peer reviewer was not credible, since she relied only on her own experience and admitted selecting favorable findings, so the peer review was a nullity and the provider recovered.
Richard A. Hellander, M.D., P.C. v State Farm Ins. Co. (2004 NY Slip Op 24468) Civil Court, Richmond County, November 22, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After trial, held the insurer failed its burden because its expert's testimony was equivocal and relied on a blanket radiology guideline that spinal ultrasound lacks utility, not on the assignor's specific symptoms, so judgment went to the provider.
Elmont Open MRI & Diagnostic Radiology, P.C. v Country Wide Ins. Co. (2004 NY Slip Op 50946(U)) District Court of Nassau County, First District, August 26, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer failed to prove lack of medical necessity because its denial rested on a nurse's review, whose medical opinions are incompetent, so the denial was ineffective, the defense precluded, and the provider won summary judgment.
A.B. Med. Servs. PLLC v Travelers Prop. Cas. Corp. (2004 NY Slip Op 24289) Civil Court of the City of New York, Kings County, August 9, 2004Insurer's proof was enough to defeat the provider's motion but not to winHeld the insurer's unsworn peer review usable because the provider opened the door by challenging it, and found it set forth a factual basis and medical rationale raising a triable issue, so the provider's motion was denied.
Prime Med. v Travelers Indem. Co. (2004 NY Slip Op 50234(U)) Civil Court of the City of New York, Kings County, April 8, 2004Trial ruling on burden or admissibility of the insurer's proof; matter sent back without a findingHeld the jury would be instructed that the insurer bore the burden of proving lack of medical necessity by a fair preponderance of the evidence, because binding Appellate Term precedent (the only appellate authority) placed that burden on the insurer.
Queens Blvd. Med. v Travelers Indem. Co. (2004 NY Slip Op 24101) Civil Court of the City of New York, Queens County, April 5, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held the insurer's expert, a psychologist without expertise in biofeedback for back pain, not competent to testify, so the insurer offered no proof of lack of medical necessity and a directed verdict followed.
Behavioral Diagnostics v Allstate Ins. Co. (2004 NY Slip Op 24041) Civil Court of the City of New York, Kings County, February 11, 2004Insurer's proof established lack of medical necessity and the provider failed to rebut itAfter trial, credited the insurer's peer-review psychologists that the testing, record reviews and explanations were unnecessary, finding the provider's inexperienced, interested expert not credible; only one record review lacking insurer testimony was awarded.
CityWide Social Work & Psychological Servs. v Travelers Indem. Co. (2004 NY Slip Op 24034) Civil Court of the City of New York, Kings County, February 11, 2004Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)Held after trial that the insurer failed its burden because its expert's opinion, standing alone, did not show the psychological testing and services were inconsistent with generally accepted professional practice, so conflicting expert views showed only a difference in judgment.
ABC Med. Mgt. v GEICO Gen. Ins. Co. (2003 NY Slip Op 23923) Civil Court of the City of New York, Queens County, December 23, 2003Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited) (also decides)Denied the insurer's summary judgment motion because it failed to submit the peer review supporting its medical-necessity defense, and the report the provider produced left contested factual issues for trial.

Trial courts in the Fourth Department (1 decision)

Daniel C. Cox D.C., P.C. v Erie Ins. Co. (2011 NY Slip Op 51194(U)) City Court of Buffalo, June 13, 2011Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)After a nonjury trial on documents, held the orthopedist's IME report, though from a qualified expert, conclusory and without an adequate medical rationale, so it did not rebut the presumption of medical necessity.

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