Specificity of Medical Literature in Peer Reviews
February 8, 2010
V&B Magic Recovery Supply and GEICO Insurance Company
AAA Case No. 412009023294 (Maria Schuchmann, awarded February 3, 2010)
Applicant brought the arbitration seeking recovery for medical supplies dispensed to the injured person including a cervical pillow, a thermophore, an LSO, an egg crate mattress and bed board, and a hot/cold pack.
Respondent denied payment for the supplies based upon a peer review that found that the supplies were not medically necessary. In part the peer reviewer argued that there was nothing to show the benefit of these supplies when the patient was receiving contemporaneous in-office rehabilitation.
Conversely, the Arbitrator found that the medical information provided by the reviewer only dealt with the use of therapeutic rehabilitation, and had nothing to do with the usefulness of medical supplies in the treatment of patient’s like the subject injured person.
In citing Nir v Allstate Ins. Co., 796 NYS2d 857, (Feb 28, 2005), the decision states:
In regard to personal injury coverage, a peer review’s medical rationale is insufficient if it is unsupported by or controverted by evidence of medical standards. For example, the medical rationale may be insufficient if not supported by evidence of generally accepted medical/professional practice. Generally accepted medical practice is that range of practice that the profession will follow in the diagnosis and treatment of patients in light of the standards and values that define its calling. Alternatively, if the plaintiff offers evidence that its medial services were consistent with generally accepted medical practice, the insurer’s peer review report will be afforded less weight and the insurer may fail to sustain its burden of proof at trial.
The reviewer’s opinion, which apparently lacked sufficient reference to the usefulness of the subject medical supplies, failed to establish that the applicant deviated from accepted medical practice in ordering the supplies. Arbitrator Schuchman added, regarding the peer review, that “[a]dding a citation or making reference to medical literature that is irrelevant does not meet the Nir standard.”
As such, the supplies at issue were found to be medically necessary and Applicant was awarded the full amount of benefits.
Roy Mura
Bethany Mazur
Scott Mancuso
