Peer Report Defeats Pip Pain Cream Charges: Value Core Pharmacy, Inc and Allstate Insurance Company.

• Date: 26 February 2018
• Author: Rogak, Lawrence

AAA Case No. 17-17-1053-2955 (Eileen Casey, arbitrator) Award date: 02/28/2018

The issue in this PIP arbitration was: Whether Applicant is entitled to no-fault reimbursement for compound pain cream denied based on a peer review?

The original amount claimed was $2,077.47 for compound pain cream provided on October 26, 2016. Applicant amended the amount claimed to $1,442.28 pursuant to the pharmacy fee schedule.

The evidence demonstrates that the EIP, a forty-five-year-old female, was injured in a motor vehicle accident on October 17, 2016.

Lack of medical necessity is a defense to an action to recover no-fault benefits, which an insurer may assert upon a timely denial, based either on a medical examination or a peer review report. Rockawa[gamma] Boulevard

Medical P.C. v. Travelers Property Casualty Corp., 2003 N.Y. Slip Op. 50842(U), 2003 WL 21049583 (App. Term 2d & 11th Dists. 2003).

Respondent denied Applicants claim based on a peer review by Dr. Jay Weiss, M.D. In his report, Dr. Weiss listed the medical records that he reviewed and detailed the EIP's pertinent medical history.

Dr. Weiss said that, based upon a review of the medical records, there was no indication for the custom compound cream. He noted that the compounded medication consists of various oral medications such as gabapentin, cyclobenzaprine, baclofen and diclofenac. Dr. Weiss added that it also includes lidocaine and menthol which are common ingredients in over-the-counter topical rubs.

Dr. Weiss explained that of the oral medications that were noted here, Diclofenac has some limited use topically, but the others are oral medications without evidence of efficacy when placed on the skin. He added that the quantities and ratio of medication utilized also has no scientific basis or medical rationale or evidence of efficacy.

Furthermore, he noted that the New York Mid and Low Back Injury Medical Treatment Guidelines concluded that topical, oral and/or systemic...