At issue in this no-fault case was the medical necessity of two MRIs. The courts decision is summarized as follows:

In this action plaintiff seeks a money judgmentin the sum of $1758.40for medical services rendered to its assignor. Defendant interposed a verified answer alleging various affirmative defenses, including the defense that there was no medical necessity for the treatment rendered to the claimant.

While the no-fault insurance law provides no definition for medical necessity, services rendered must fall within the standards of generally accepted medical practice and should be based on the physicians objectively reasonable belief that it will further the patients diagnosis and treatment.

In this case, Doctor Isandr Dumesh gave his medical opinion that the MRIs of the right shoulder and spine were not medically necessary. Dr. Dumesh testifiedthat in this case the patient was undergoing physical therapy for about four weeks when the referring doctor ordered the MRIs. However, the referring doctor gave no indication that the physical therapy was not working to warrant the necessity of the MRI studies, and/or why the MRI studies would alter the treatment regimen. Dr. Dumesh observed that this patients injuries after the accident were moderate, i.e., the patient was discharged from the emergency room, could ambulate on his own, and then received physical therapy for about four weeks consisting of acupuncture, massage, and rest. According to Dr. Dumesh, an alternate treatment plan could consist of injections if the physical therapy wasnt working. However, where surgery was not contemplated, as in this case, ordering the MRI was unnecessary because even the finding of herniated discs would not alter the treatment plan.

After review of the credible evidence, the court finds that the defendant prevailed in its first burden that the services rendered were not medically necessary, shifting the burden to plaintiff. However, plaintiff did not present a medical witness to rebut defendants evidence. For the foregoing reasons, the complaint is dismissed with prejudice.

Comment: While not discussed in the courts decision, a ruling was made at trial which involves an issue that is growing in importance: plaintiffs attorney objected to the peer review doctors testimony about what he read in the claimants medicals, on the grounds of hearsay. Judge Rodriguez overruled the objection, holding that the no-fault scheme contemplates that the claimants doctor will provide medical reports to the insurer which may then be reviewed by the peer review doctor and relied upon in reaching his conclusions. The medicals are therefore a business record and the peer review process overcomes the hearsay objection.

Andrew Carothers MD PC a/a/o Ricardo Cymiaque v. Citiwide Auto Leasing Inc., Index no. 46251/2005 (Civil Court, Bronx County) (JULIA RODRIGUEZ, j)