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

Case No. 2016-1458 K C
Regular Panel Decision
Nov 09, 2018

Pavlova v. Allstate Ins. Co.

This case concerns an appeal regarding first-party no-fault benefits sought by Ksenia Pavlova, D.O., as assignee of Cosby Reavis, against Allstate Insurance Company. The Civil Court had denied the plaintiff's motion for summary judgment and partially granted the defendant's cross-motion, dismissing claims for services billed under CPT code 20999, arguing plaintiff was not entitled to payment under the workers' compensation fee schedule. The Appellate Term modified the Civil Court's order, finding that Allstate's denial of claims for CPT code 20999 was without merit because the insurer failed to request additional documentation as required by 11 NYCRR 65-3.5(b) for "By Report" codes. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, noting the plaintiff failed to demonstrate that claims were not timely denied or that denials were conclusory. The matter was remitted to the Civil Court for a determination on the medical necessity of the CPT code 20999 services, a ground not previously addressed.

No-Fault BenefitsSummary JudgmentAppellate TermCPT Code 20999Workers' Compensation Fee ScheduleMedical NecessityClaim DenialVerification Request11 NYCRR 65-3.5(b)Insurance Law
References
0
Case No. 2016-329 S C
Regular Panel Decision
Apr 27, 2017

Spineisland for Chiropractic, P.C. v. 21st Century Advantage Ins. Co.

This case involves an appeal by Spineisland For Chiropractic, P.C., acting as an assignee, against 21st Century Advantage Insurance Company concerning first-party no-fault benefits. The plaintiff sought to recover for services billed under CPT code 95831. The District Court of Suffolk County had previously granted the defendant's motion for summary judgment, asserting that the defendant had appropriately paid the plaintiff based on the workers' compensation fee schedule. On appeal, the Appellate Term affirmed the lower court's decision. The Appellate Term found that the defendant had adequately demonstrated the proper application of CPT code 95833 for the services billed under CPT code 95831, and the plaintiff failed to present a triable issue of fact.

No-fault benefitsSummary judgmentCPT codeWorkers' compensation fee scheduleAppellate TermSuffolk CountyAssigneeInsurance disputeChiropractic servicesMedical billing
References
1
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. 570163/16
Regular Panel Decision
Sep 19, 2016

Urban Well Acupuncture, P.C. v. Erie Ins. Co. of N.Y.

Defendant appealed from an order of the Civil Court of the City of New York, New York County (Paul A. Goetz, J.), entered March 12, 2015, which denied its motion for summary judgment dismissing the complaint. The Appellate Term, First Department, modified the order by granting defendant partial summary judgment dismissing plaintiff's claim for first-party no-fault benefits billed under CPT codes 97813 and 97814; as modified, order affirmed, without costs. The court found that the defendant established it timely denied the no-fault claims for CPT codes 97813 and 97814 because the amounts charged were in excess of the applicable worker's compensation fee schedule. Plaintiff failed to raise a triable issue regarding the efficacy of the mailing or the fee calculation for these claims. However, triable issues remain concerning whether defendant properly denied the claim for $70 billed under CPT code 99202 (initial evaluation).

Summary JudgmentNo-Fault BenefitsCPT CodesMedical BillingAppellate ReviewFirst-Party ClaimsInsurance DenialsWorker's Compensation Fee ScheduleTriable Issues
References
4
Case No. MISSING
Regular Panel Decision
Jun 30, 2010

John Giugliano, DC, P.C. v. Merchants Mutual Insurance

Plaintiff John Giugliano, DC, EC., as assignee of Laura Hebenstreit, initiated this action to recover first party no-fault benefits from defendant Merchants Mutual Ins. Co. The core dispute, following a trial on June 30, 2010, centered on the plaintiff's billing practices under the New York Workers' Compensation Medical Fee Schedule, specifically regarding the use of surgical CPT codes for chiropractic procedures. Defendant argued against the use of surgical codes and duplicate billing for a specific CPT code, while plaintiff maintained these practices were justified because the procedures were not listed under the chiropractic fee schedule and involved distinct treatment areas. The court ultimately ruled in favor of the plaintiff, concluding that the procedures were properly billed according to the Fee Schedule, thereby entitling the plaintiff to reimbursement.

No-Fault BenefitsChiropractic BillingWorkers' Compensation Fee ScheduleCPT CodesSurgical ProceduresCo-Surgeon BillingInsurance ReimbursementMedical Fee Schedule DisputesSpinal ManipulationMandibular Fracture
References
2
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. 2015-451 K C
Regular Panel Decision
Dec 22, 2017

Z.M.S. & Y Acupuncture, P.C. v. GEICO Gen. Ins. Co.

This case concerns an action by Z.M.S. & Y Acupuncture, P.C., as assignee of Melo, Carmen, to recover assigned first-party no-fault benefits from GEICO General Insurance Company. The plaintiff moved for summary judgment, while the defendant cross-moved to dismiss claims. The Civil Court of the City of New York, Kings County, limited the issues for trial regarding the application of the workers' compensation fee schedule to services billed under specific CPT codes. On appeal to the Appellate Term, Second Department, the Civil Court's order was modified. The Appellate Term granted the branches of GEICO's cross motion seeking summary judgment dismissing claims for services under CPT codes 97811, 97813, and 97814, and as so modified, affirmed the order.

no-fault benefitsacupuncturesummary judgmentCPT codesworkers' compensation fee scheduleAppellate Terminsurance claimprofessional corporationsassigned benefits
References
1
Case No. 2015-608 Q C
Regular Panel Decision
Dec 19, 2017

Adelaida Physical Therapy, P.C. v. 21st Century Ins. Co.

In this case, Adelaida Physical Therapy, P.C., acting as an assignee, appealed an order from the Civil Court of the City of New York, Queens County. The original order had granted 21st Century Insurance Company's motion for summary judgment, dismissing parts of a complaint seeking first-party no-fault benefits for services billed under specific CPT codes (97010, 97110, and 97124). The Appellate Term, Second Department, reversed the lower court's decision. The appellate court found that 21st Century Insurance Company failed to demonstrate that it had used the correct conversion factor to calculate the reimbursement rate, thus not establishing its defense that the charged fees exceeded the workers' compensation fee schedule. As a result, the branches of the defendant's motion for summary judgment related to those CPT codes were denied.

No-Fault BenefitsCPT CodesSummary JudgmentWorkers' Compensation Fee ScheduleReimbursement RateAppellate ReviewInsurance DisputeCivil ProcedureConversion FactorMedical Billing
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. 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
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