Key Takeaway
Court ruling in Five Boro Psychological v GEICO clarifies that insurers don't need to provide medical records when defending medical necessity denials in no-fault cases.
This article is part of our ongoing medical necessity coverage, with 176 published articles analyzing medical necessity issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
The “Mr. Five Boro” moniker has become synonymous with unfavorable outcomes for healthcare providers in New York’s no-fault insurance system. This particular case from the Appellate Term demonstrates how insurers can successfully defend against provider claims by establishing proper procedural grounds for benefit denials, even without extensive documentation requirements.
Key Takeaway
Insurers defending medical necessity denials in New York no-fault cases are not required to annex copies of the medical records reviewed by their peer reviewers—the peer review report alone can satisfy the evidentiary burden on summary judgment.
The Medical Records Question in No-Fault Defense
In Five Boro Psychological Services v GEICO, the court addressed a fundamental question about what evidence insurers must present when defending medical necessity denials. The ruling clarifies the evidentiary burden placed on insurance companies during summary judgment proceedings, particularly regarding peer review documentation standards.
This decision has significant implications for how providers approach litigation against insurers who deny claims based on medical necessity determinations. Understanding these procedural requirements becomes crucial when healthcare providers consider whether to pursue summary judgment motions against no-fault carriers.
Jason Tenenbaum’s Analysis
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co., 2012 NY Slip Op 51013(U)(App. Term 2d Dept. 2012)
“In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from so much of an order as denied its motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint. The Civil Court found that defendant had established that it had timely denied the subject claims on the ground that the services at issue were not medically necessary, and that plaintiff had failed to rebut defendant’s evidence. A judgment was subsequently entered, from which this appeal is deemed to have been taken.
Contrary to plaintiff’s argument on appeal, defendant was not required to annex to its motion papers copies of the medical records which were reviewed by defendant’s peer reviewer.”
You always know that when Mr. Five Boro appears, something bad will happen to the plaintiff’s bar.
What This Means for No-Fault Litigation
This ruling establishes that insurance companies defending medical necessity disputes don’t need to provide copies of the underlying medical records reviewed by their peer reviewers during summary judgment proceedings. The decision reinforces that insurers can meet their evidentiary burden through peer review reports alone, making it more challenging for providers to successfully challenge these denials in court.
For personal injury practitioners representing providers and claimants, this lower evidentiary threshold means the focus must shift to substantive challenges to the peer review conclusions rather than procedural attacks on the insurer’s documentary submissions.
Legal Update (February 2026): Since this 2012 decision, New York’s no-fault regulations have undergone significant revisions, including amendments to medical necessity review procedures and evidentiary standards for insurer defenses. The peer review documentation requirements and summary judgment standards discussed in this Five Boro case may have been modified through subsequent regulatory changes and appellate decisions. Practitioners should verify current provisions of the Insurance Law and applicable regulations when evaluating similar medical necessity disputes.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Medical Necessity Disputes in No-Fault Insurance
Medical necessity is the most common basis for no-fault claim denials in New York. Insurers hire peer reviewers to opine that treatment was not medically necessary, shifting the burden to providers and claimants to demonstrate otherwise. The legal standards for establishing and rebutting medical necessity — including the sufficiency of peer review reports, the qualifications of reviewing physicians, and the evidentiary burdens at arbitration and trial — are the subject of extensive case law. These articles provide detailed analysis of medical necessity litigation strategies and court decisions.
176 published articles in Medical Necessity
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Mar 26, 2015Frequently Asked Questions
Common Questions About This Topic
4 answers from the firm's New York personal-injury and employment-law practice. Click any question to expand.
What did the court rule in Five Boro Psychological v GEICO?
The Appellate Term held that insurers defending medical necessity denials are not required to annex copies of the medical records reviewed by their peer reviewer to their summary judgment motion papers. The peer review report alone can be sufficient.
Do insurers need to provide medical records with peer review reports in New York no-fault cases?
No. Under this ruling, insurance carriers can meet their evidentiary burden through the peer review report alone, without attaching copies of the underlying medical records that were reviewed. This makes it easier for carriers to defend medical necessity denials.
What is a medical necessity denial in New York no-fault insurance?
A medical necessity denial is when an insurance carrier refuses to pay for medical treatment, arguing the services were not medically necessary for the claimant's injuries. Carriers typically support these denials with peer review reports from medical professionals who review the claimant's records.
How does this ruling affect healthcare providers challenging no-fault denials on Long Island?
This ruling makes it more challenging for providers to defeat summary judgment motions in medical necessity cases, since insurers face a lower documentary burden. Providers must focus on rebutting the substance of peer review conclusions rather than challenging procedural deficiencies in the insurer's motion papers.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a medical necessity matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
