CITIZENS UNITED RECIPROCAL EXCHANGE VS. NORTHERN NJ ORTHO SPECIALISTS (L-1933-15, MORRIS COUNTY AND STATEWIDE), A-1669-15T3

CURE (insurer) denied pre-certification for surgery by Northern NJ Ortho Specialists (Ortho) for CURE's insured, concluding surgery was not medically necessary after independent medical examinations (MRO determination).
Ortho performed the surgery anyway, submitted a claim, and demanded payment; CURE refused and the dispute proceeded to APDRA arbitration.
At arbitration, CURE relied on an MRO report presuming the denial correct; Ortho submitted its own expert report contradicting the MRO and argued it rebutted that presumption.
The arbitrator found Ortho had rebutted the MRO presumption and awarded payment to Ortho; CURE sought clarification and then moved in the Law Division to vacate under N.J.S.A. 2A:23A-13(c).
The Law Division confirmed the award, concluding CURE failed to show legal error or that Ortho was barred from submitting a rebuttal report; the court declined to reweigh factual determinations supported by substantial evidence.
CURE appealed to the Appellate Division arguing the trial court misapplied statutory standards (No‑Fault Act and regulation) regarding the MRO presumption and evidence submitted after the MRO report.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Ortho could rebut the MRO determination with its own expert report	CURE: MRO determination is presumptively correct and Ortho's submission was insufficient to overcome presumption	Ortho: Presumption is rebuttable by preponderance; its expert evidence did so	Held: Ortho's evidence rebutted the MRO; arbitrator's factual finding was supported by substantial evidence
Whether the Law Division misapplied statutory/regulatory standards (N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-29.4)	CURE: Trial court failed to apply required standards and regs, implicating public policy warranting appellate review	Ortho: Trial court correctly applied APDRA standards and reviewed for statutory grounds only	Held: No significant public policy issue; trial court acted within APDRA authority; appeal dismissed
Whether the arbitration award should be vacated for legal error under APDRA	CURE: Award rests on erroneous application of law (MRO presumption)	Ortho: Award rests on permissible factual and legal determinations by arbitrator	Held: No basis to vacate; APDRA limits review and trial court’s confirmation was proper
Whether appellate review is available despite N.J.S.A. 2A:23A-18(b) bar	CURE: Exception should apply due to public policy and statutory/regulatory misapplication	Ortho: No exception applies; Mt. Hope and related precedent limit appellate review	Held: No exception present; appellate jurisdiction lacking and dismissal required

Mt. Hope Dev. Assocs. v. Mt. Hope Waterpower Project, L.P., 154 N.J. 141 (recognizing APDRA's waiver of further appellate review except in narrow circumstances)
Johnson v. Johnson, 204 N.J. 529 (APDRA requires awards to be grounded in applicable legal principles and sets procedures for findings)
Selective Ins. Co. of Am. v. Rothman, 414 N.J. Super. 331 (discussing APDRA review standards)
N.J. Citizens Underwriting Reciprocal Exch. v. Kieran Collins, D.C., LLC, 399 N.J. Super. 40 (appellate scope limited when trial court adheres to APDRA grounds)
Fort Lee Surgery Ctr., Inc. v. Proformance Ins. Co., 412 N.J. Super. 99 (broad appellate review conflicts with APDRA intent)
Riverside Chiropractic Grp. v. Mercury Ins. Co., 404 N.J. Super. 228 (only "glaring errors" justify appellate intrusion)
Morel v. State Farm Ins. Co., 396 N.J. Super. 472 (limitations on appellate review; public policy exception narrow)
Allstate Ins. Co. v. Sabato, 380 N.J. Super. 463 (examples of limited exceptions to APDRA bar)
Cobo v. Market Transition Facility, 293 N.J. Super. 374 (PIP coverage and payment of reasonable medical expenses)