Medical Literature Cited in Peer Review Subject to Review by Arbitrator

I thought this was interesting.

Brookhaven Orthopedic Associates and Geico Insurance Company, AAA Case No. 412009033877 (Walter Higgins, awarded Dec 14, 2009)

The applicant had established its prima facie entitlement to benefits by proof that it submitted completed claims forms setting forth the fact and amount of the loss sustained, and that payment of No-Fault benefits was overdue as is required under A.B. Medical Services v GEICO, 7 Misc3d 133A; see also Amaze Med. Supply v Eagle Ins. Co., 2 Misc3d 128A.

The respondent failed to rebut the presumption of medical necessity, and therefore failed to establish the lack of medical necessity for the services, as Arbitrator Higgins was not persuaded by the peer review submitted by the respondent.  Higgins found that the peer review report in support of the denial did not “set forth a sufficient factual basis or medical rationale based upon generally accepted medical practice to justify denial.”

In the report, the peer reviewer did cite published medical literature in support of his finding that an MRI of the EIP’s shoulder was not medically necessary before more conservative treatment was administered.  However, the arbitrator reviewed the literature himself and found that it dealt “only with asymptomatic patients, and makes no mention of conservative care, and is not supportive of the peer reviewer’s opinion.”

So, although an IME doctor or other peer reviewer may cite medical literature in support of her opinion, an arbitrator is apparently still free to review that literature and make his own decision as to whether it supports the peer reviewer’s opinion.