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Case Law Database

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

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. 46885/05, 47943/05, 47945/05
Regular Panel Decision

Robert Physical Therapy, P.C. v. State Farm Mutual Automobile Insurance

This case involves three consolidated claims for first-party no-fault benefits related to physical therapy services. The plaintiff's assignors received physical therapy, and the defendant, an insurer, denied some claims due to disputes over billing codes. The central legal issues concerned whether a physical therapist could utilize billing codes from the medicine fee schedule when such services were not explicitly in the physical medicine schedule, and if range of motion and muscle testing could be billed separately from evaluation and management on the same day. The court determined that physical therapists are not confined to the physical medicine section and can use codes from any section of the medical fee schedule. Furthermore, the defendant failed to provide sufficient evidence to justify its denials regarding separate billing for range of motion and muscle testing. Consequently, the court ruled in favor of the plaintiff, awarding judgment for all disputed amounts.

Physical Therapy BillingNo-Fault BenefitsMedical Fee ScheduleCPT CodesWorkers' Compensation RegulationsEvaluation and Management ServicesRange of Motion TestingMuscle TestingProvider SpecialtyBilling Disputes
References
4
Case No. 2015-2337 Q C
Regular Panel Decision
May 18, 2018

Sama Physical Therapy, P.C. v. Hereford Ins. Co.

This case concerns an action by Sama Physical Therapy, P.C., as assignee, to recover first-party no-fault benefits from Hereford Insurance Co. The defendant argued that the plaintiff's assignor had been injured during the course of employment. The Civil Court conditionally granted defendant's cross-motion for summary judgment, ordering the plaintiff to file an application with the Workers' Compensation Board within 90 days. Plaintiff failed to comply with this order, and upon renewal, the Civil Court adhered to its prior determination. The Appellate Term, Second Department, affirmed the Civil Court's order, finding that the plaintiff did not demonstrate compliance with the order to make a proper application under the Workers' Compensation Law.

No-Fault BenefitsSummary JudgmentWorkers' Compensation BoardAppellate ReviewConditional GrantFailure to ComplyRenewal MotionInsurance LawAssigneeMedical Provider
References
1
Case No. 2016-198 Q C
Regular Panel Decision
Jun 01, 2018

Comprehensive Care Physical Therapy, P.C. v. Allstate Ins. Co.

This case concerns a provider, Comprehensive Care Physical Therapy, P.C., seeking no-fault benefits from Allstate Insurance Company. The Civil Court initially denied the plaintiff's summary judgment motion and granted the defendant's cross-motion, dismissing the complaint based on the assignor's failure to appear for independent medical examinations (IMEs) and claims exceeding the fee schedule. On appeal, the Appellate Term modified this order, finding that Allstate failed to provide sufficient proof of timely denial form mailing, thereby precluding its defenses regarding IMEs and the fee schedule. Consequently, Allstate's cross-motion for summary judgment was denied, reversing that part of the lower court's decision. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, as the plaintiff also failed to establish their claims.

no-fault insurancesummary judgmentindependent medical examinationstimely denialinsurance defenseappellate reviewmedical billingassignee rightsprocedural requirementsfee schedule
References
5
Case No. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
6
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
Case No. ADJ4647589
Regular
Dec 10, 2019

ORIS PAYTON vs. CAL EXPO FAIRGROUNDS, CALIFORNIA FAIR SERVICES AUTHORITY

The Workers' Compensation Appeals Board (WCAB) denied the applicant's petition for reconsideration. The applicant sought further physical therapy beyond the statutory limit of 24 visits. The WCAB adopted the Workers' Compensation Administrative Law Judge's report, which concluded that the WCAB lacks the authority to challenge the constitutionality of a statute, including Labor Code section 4604.5, which limits physical therapy visits. Therefore, the applicant's request for treatment exceeding the statutory allowance was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeFindings and AwardIndustrial InjuryCumulative Work ActivitiesMedical TreatmentPhysical TherapyStipulationsAgreed Medical Examiner
References
3
Case No. ADJ8266885
Regular
Jan 20, 2016

DAYSI PATRICIA MOLINA ROMERO vs. CALIFORNIA PIZZA KITCHEN, TRAVELERS DIAMOND BAR

This case involves a lien claim by Mario Arroyo, D.C., for chiropractic and physical therapy services provided to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded the original findings. The WCAB held that "visits" must be distinguished by the type of treatment rendered, allowing for separate reimbursement caps for chiropractic and physical therapy visits. Further development of the record is required to determine the nature of services provided and whether Arroyo is entitled to reimbursement for physical therapy beyond the 24 chiropractic visits already paid.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderLien ClaimantChiropractic VisitsPhysical TherapyLabor Code Section 4604.5(c)(1)Bill ReviewerCumulative TraumaIndustrial Injury
References
2
Case No. MISSING
Regular Panel Decision

Claim of Capon v. Grumman Corp.

William Capon sustained compensable injuries to his left leg in 1970 and 1983. In the latter incident, he fractured his femur, requiring surgery. Following his hospital discharge, Capon began physical therapy with Louis Cress. On April 8, 1983, after a reportedly strenuous therapy session, Capon suffered a fatal heart attack approximately one hour after returning home. His wife, the claimant, applied for workers' compensation benefits. The Workers’ Compensation Board sustained the claim, based on Dr. Irwin Friedman's testimony that the heart attack was causally related to the stress of the physical therapy. The employer appealed, contending that Friedman's testimony lacked substantial evidence. The court found adequate evidentiary support in the physical therapist's report and the claimant's testimony regarding Capon's condition, affirming the Board's decision.

Workers' Compensation BenefitsCausal ConnectionFatal Heart AttackStress-Induced InjuryPhysical Therapy ComplicationsMedical Expert TestimonyAppellate Court ReviewSubstantial Evidence RuleEmployer AppealDecedent's Claim
References
2
Case No. 2014-1124 K C
Regular Panel Decision
Jul 21, 2017

Natural Therapy Acupuncture, P.C. v. Nationwide Ins.

The Appellate Term, Second Department, affirmed an order of the Civil Court of the City of New York, Kings County, which had granted summary judgment to Nationwide Ins. The case involved Natural Therapy Acupuncture, P.C.'s action to recover assigned first-party no-fault benefits. Nationwide Ins. successfully argued that it properly reimbursed the plaintiff for acupuncture services using the workers' compensation fee schedule applicable to chiropractors providing similar services. The appellate court found sufficient proof of timely mailing of claim denials and full payment according to the fee schedule. A new contention raised by the plaintiff for the first time on appeal was not considered by the court.

no-fault insuranceacupuncture servicesworkers' compensation fee schedulesummary judgmentappellate reviewclaim denialtimely mailingreimbursementmedical servicesfirst-party benefits
References
4
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