Medical Necessity

The Sigalov Firm PLLC specializes in the collection and arbitration of no-fault medical claims

Medical Necessity

Frequently, insurance carriers will deny a healthcare provider’s claim on the ground that the procedures, tests, or medical supplies were not medically necessary, even though they really were. To support the denial, the insurance carrier typically provides an expert opinion from a doctor. This expert opinion is commonly known as a “peer review,” and the doctor providing the opinion is commonly known as a “peer review doctor.”

Peer review doctors are supposedly qualified and unbiased doctors who perform a comprehensive review of the medical record to make an honest determination about whether the healthcare service was necessary. However, how can we trust the opinion of a peer review doctor to be unbiased when the doctor earns a substantial portion of his income by providing insurance carriers with peer review opinions? In fact, we know of at least one insurance carrier that frequently makes use of a peer review doctor who was found to have violated mandatory standards during his testimony in legal proceedings. This insurance carrier continues to use this doctor for peer review opinions.

The Sigalov Firm is expert at winning claims denied for lack of medical necessity. Our strength is the ability to discredit the peer reviewer’s medical report. Here are some ways we are able to discredit the peer reviewer:

  1. By citing logical fallacies in the peer reviewer’s report
  2. By citing the peer reviewer’s failure to correctly articulate the medical standard
  3. By citing the peer reviewer’s failure to address positive findings in the medical records
  4. By citing the peer reviewer’s failure to submit medical publications relied on in his opinion
  5. By discrediting the peer reviewer’s credentials–and sometimes even discrediting the peer reviewer himself