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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. 2016-119 K C
Regular Panel Decision
Jul 06, 2018

Jing Luo Acupuncture, P.C. v. NY City Tr. Auth.

This case involves an appeal from an order and judgment concerning a claim for first-party no-fault benefits for acupuncture services. The plaintiff, Jing Luo Acupuncture, P.C., as assignee of Sarah Adams, sought to recover unpaid balances from the NY City Transit Authority. The Civil Court initially granted the plaintiff's motion for summary judgment and denied the defendant's cross-motion. On appeal, the Appellate Term reversed the judgment, finding that the plaintiff failed to establish prima facie entitlement to summary judgment. The court also held that the defendant was not precluded from interposing its fee schedule defense, as it had fully paid for services billed under CPT codes 97811, 97813, and 97814 according to the workers' compensation fee schedule. Consequently, the plaintiff's motion for summary judgment was denied, and the defendant's cross-motion was granted in part for those specific CPT codes, while denied for CPT code 99262 and the seventh cause of action.

Acupuncture ServicesNo-Fault BenefitsSummary JudgmentFee Schedule DefenseWorkers' Compensation Fee ScheduleCPT CodesAppellate ReviewInsurance LawTimely DenialFirst-Party Benefits
References
14
Case No. 2017 NY Slip Op 51149(U)
Regular Panel Decision
Sep 08, 2017

Charles Deng Acupuncture, P.C. v. ELRAC, Inc.

This case concerns an appeal regarding first-party no-fault benefits. The plaintiff, Charles Deng Acupuncture, P.C., sought to recover for acupuncture services provided to Sarae Gomez, which were billed under CPT codes 97810 and 97811. The defendant, ELRAC, Inc., had reduced the payments based on the workers' compensation fee schedule applicable to acupuncture services performed by chiropractors. The Appellate Term affirmed the Civil Court's decision, holding that an insurer is permitted to use the workers' compensation fee schedule for chiropractic acupuncture services to determine the reimbursement amount for licensed acupuncturists, thereby upholding the dismissal of the plaintiff's claim for the disputed services.

No-fault benefitsAcupuncture servicesCPT codes 97810CPT codes 97811Workers' compensation fee scheduleSummary judgmentAppellate reviewFee reductionLicensed acupuncturistChiropractic services
References
1
Case No. 2015-432 K C
Regular Panel Decision
Dec 22, 2017

Oleg's Acupuncture, P.C. v. GEICO Gen. Ins. Co.

This case involves an appeal by GEICO General Insurance Company against Oleg's Acupuncture, P.C., concerning first-party no-fault benefits. The Appellate Term reversed an order from the Civil Court that had denied GEICO's cross-motion for summary judgment. The court found that GEICO had timely mailed denial of claim forms and had fully compensated Oleg's Acupuncture for services billed under CPT codes 97813 and 97814, in accordance with the workers' compensation fee schedule for acupuncture services. The plaintiff failed to present a triable issue of fact in opposition to GEICO's evidence.

no-fault benefitsacupuncture servicesworkers' compensation fee schedulesummary judgmentCPT codestimely mailinginsurance claimassigneeAppellate TermCivil Court
References
4
Case No. 2014-2497 Q C
Regular Panel Decision
Oct 27, 2017

Charles Deng Acupuncture, P.C. v. State Farm Mut. Auto. Ins. Co.

This case involves an appeal by Charles Deng Acupuncture, P.C., as assignee of Blake, Christopher, against State Farm Mutual Automobile Ins. Co. The plaintiff sought summary judgment for unpaid first-party no-fault benefits related to acupuncture services, specifically claims billed under CPT codes 97810, 97811, and 99203. The Civil Court partially granted the plaintiff's motion for a reduced amount on one claim and dismissed the rest, also granting the defendant's cross-motion for dismissal. On appeal, the Appellate Term, Second Department, affirmed the Civil Court's order. The court found that State Farm had timely mailed denial of claim forms and had properly paid the services according to the workers' compensation fee schedule for acupuncture services performed by chiropractors.

no-fault benefitsacupuncture servicesworkers' compensation fee schedulesummary judgmentCPT codesmedical billinginsurance disputeappellate reviewtimely mailingdenial of claim
References
2
Case No. 2017-303 K C
Regular Panel Decision
Apr 12, 2019

GL Acupuncture, P.C. v. Progressive Ins. Co.

This case involves an appeal by GL Acupuncture, P.C. from a judgment of the Civil Court of the City of New York, Kings County. The plaintiff sought to recover assigned first-party no-fault benefits for acupuncture services. The Civil Court, after a nonjury trial, awarded the plaintiff only $54.74, finding that the defendant had properly paid the claims based on the workers' compensation chiropractic fee schedule. The Appellate Term, Second Department, affirmed the judgment, concurring that the Civil Court correctly determined that the defendant had fully paid for the services billed under CPT codes 97810 and 97811 in accordance with the fee schedule, and that the plaintiff failed to rebut this showing.

Acupuncture servicesNo-fault benefitsChiropractic fee scheduleCPT codesAssigned claimsInsurance disputePrima facie caseCredibilityAppellate reviewCivil Court judgment
References
1
Case No. 2014-781 Q C
Regular Panel Decision
Sep 27, 2016

Gl Acupuncture, P.C. v. Praetorian Ins. Co.

This case involves an appeal by GL Acupuncture, P.C., as assignee of Kenya M. Jones, against Praetorian Ins. Co. The appeal concerned an order from the Civil Court of the City of New York, Queens County, which had granted the defendant's cross motion for summary judgment to dismiss several causes of action for assigned first-party no-fault benefits. The Appellate Term found that while the defendant's proof was sufficient regarding the mailing of denial forms and payments for certain CPT codes, it failed to provide enough evidence to dismiss the plaintiff's claim for an initial acupuncture visit on July 8, 2010. Consequently, the order was modified to deny the dismissal of this specific claim, and affirmed as so modified.

No-fault benefitsSummary judgmentAppellate reviewAcupuncture servicesInsurance claimsWorkers' compensation fee scheduleDenial of claimMedical billingCivil court appealFirst-party benefits
References
2
Case No. 2015-976 K C
Regular Panel Decision
Dec 22, 2017

Acuhealth Acupuncture, P.C. v. Hereford Ins. Co.

This case concerns an appeal from an order of the Civil Court regarding a dispute between Acuhealth Acupuncture, P.C. (applicant) and Hereford Ins. Co. (defendant) over first-party no-fault benefits. The applicant sought recovery for services billed under CPT code 97039, which has a 'By Report' designation in the workers' compensation fee schedule requiring additional documentation. The Civil Court initially granted the defendant's motion for summary judgment and denied the applicant's cross-motion. On appeal, the Appellate Term modified the order, denying the branch of the defendant's motion seeking summary judgment on the CPT code 97039 claims, as the defendant failed to demonstrate it requested the required additional verification. However, the applicant's cross-motion for summary judgment was still denied as it failed to establish its prima facie entitlement to judgment.

No-fault insuranceSummary judgment motionCPT codeWorkers' compensation fee scheduleVerification of claimAppellate reviewMedical billing disputeInsurance benefitsAssignee claimCivil procedure
References
5
Case No. 2016-334 S C
Regular Panel Decision
Apr 27, 2017

2 & 9 Acupuncture, P.C. v. 21st Century Advantage Ins. Co.

This case concerns an appeal by 2 & 9 Acupuncture, P.C. from an amended order that granted summary judgment to 21st Century Advantage Insurance Company, dismissing a complaint to recover assigned first-party no-fault benefits. The defendant argued it had paid the plaintiff in accordance with the workers' compensation fee schedule. The Appellate Term, Second Department, reversed the lower court's decision, finding that the defendant failed to prima facie demonstrate proper denial of payment for services billed under CPT codes 97026 and 97016. Consequently, the defendant's motion for summary judgment regarding these specific CPT codes was denied.

No-Fault BenefitsSummary JudgmentCPT CodesWorkers' CompensationAppellate ReviewInsurance LawMedical BillingAcupunctureSuffolk CountyPayment Dispute
References
3
Case No. 2015-447 K C
Regular Panel Decision
Dec 19, 2017

Precious Acupuncture Care, P.C. v. GEICO Gen. Ins. Co.

Precious Acupuncture Care, P.C., as assignee of Vorel Hopkins, initiated an action against GEICO General Insurance Company to recover assigned first-party no-fault benefits. The plaintiff moved for summary judgment, while the defendant cross-moved for summary judgment to dismiss claims for services rendered on March 4 and 6, 2013, due to untimely submission, and other claims arguing full payment according to the workers' compensation fee schedule for services billed under CPT codes 97813 and 97814. The Civil Court denied the defendant's cross-motion. The Appellate Term, Second Department, reversed the Civil Court's order, finding that the defendant had presented sufficient proof of full payment for the CPT code services in line with the workers' compensation fee schedule and that the claims from March 4 and 6, 2013, were indeed untimely submitted. Consequently, the defendant's cross-motion for summary judgment regarding these specific claims was granted.

No-Fault BenefitsAcupuncture ServicesSummary JudgmentCPT CodesWorkers' Compensation Fee ScheduleUntimely SubmissionAppellate ReviewCivil Court OrderInsurance Claim
References
2
Case No. 2015-1078 K C
Regular Panel Decision
Jan 20, 2017

Bronx Acupuncture Therapy, P.C. v. Hereford Ins. Co.

This case involves Bronx Acupuncture Therapy, P.C., as assignee of Niurka Mejia, appealing an order from the Civil Court of the City of New York, Kings County. The defendant, Hereford Ins. Co., had moved for summary judgment, arguing full payment according to workers' compensation fee schedules. The Civil Court granted the motion, dismissing claims for services billed under codes 97039 (unlisted modality) and 99199 (unlisted special service). The Appellate Term reversed this decision, finding that the defendant failed to request additional verification within 15 business days for these "By Report" designated codes, as required by 11 NYCRR 65-3.5 (b). Therefore, the defendant was not entitled to summary judgment.

No-Fault BenefitsSummary JudgmentAppellate TermWorkers' Compensation Fee ScheduleUnlisted Medical CodesVerification of ClaimsMoxibustionAcupressureInsurance DisputeHealthcare Provider Reimbursement
References
2
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