Judge Philip Straniere
Provider Forest Rehabilitation Medicine sued insurer GEICO arguing it failed to pay first party no-fault medical benefits Forest rendered to its assignee, Russo. GEICO previously denied payment for lack of medical necessity for services of high frequency pulsed electromagnetic stimulation treatments using a TMR 1200 machine performed by Forest on Russo. Denial was based on a peer review by Dr. Weiland, who was unavailable to testify, hence, Dr. Weisman testified instead. Weisman agreed with Weiland’s conclusion the procedure was not medically necessary contending, also, the TMR was not generally accepted in the medical community as a valid treatment option. The court noted the conclusion expressed by Weisman could not be accepted as they were beyond the scope of Weiland’s peer review. However, the court concluded there was no evidence the therapy was widely accepted in the medical community for the treatment for which Forest used it on Russo. Further, Forest failed to rebut GEICO’s expert’s opinion on the issue, and failed to rebut GEICO’s defense, thus, the claim for reimbursement was denied and Forest’s cause of action dismissed.
