Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

A decision decides this question when it rules on the merits of an insurer's defense (or an insurer's own claim, e.g. in a de novo action or declaratory action) that a provider's charges exceed what the fee schedules allow (Insurance Law § 5108; 11 NYCRR Part 68), and says whether the insurer's proof established that excess. That includes disputes over the calculation itself (codes, relative values, conversion factors, ground rules, bundling, unit limits) and over which schedule or rate governs (licensed acupuncturists at the chiropractor or physician rate, the New Jersey schedule for out-of-state services under 11 NYCRR 68.6, the DME 150%-of-cost rule, OBS facility fees). Typical rulings: a coder's or examiner's affidavit explaining the calculation was or was not enough; the insurer failed to establish the defense as a matter of law; after trial the insurer did or did not prove its calculation.

Settled at the Appellate Division, no conflicting department. No Court of Appeals decision states what proof the insurer needs; Government Empls. Ins. Co. v Avanguard (2016) decides only that OBS facility fees are not payable under the schedules. The working rule comes from the Appellate Terms and is applied without disagreement by the Second and First Departments: the insurer bears the burden; a timely denial alone, or a conclusory statement that the claim underwent a 'fee schedule review', is not enough; an affidavit of a certified coder or trained claims examiner explaining the codes, relative values, conversion factor and ground rules, with the schedule annexed or judicially noticed, establishes the defense prima facie; a provider's opposition by counsel's affirmation alone does not raise an issue. Courts differ only at the edges: the rate for licensed acupuncturists (Appellate Term, Second Department treats the chiropractor schedule as correct as a matter of law; the First Department in Global Liberty v Acupuncture Now (2019) held that this does not foreclose the physician schedule in every case) and whether a non-certified examiner suffices.

Leading authorities · Authority map · Decisions by court · Plain-text version (Markdown)

Leading authorities

Allstate Ins. Co. v Buffalo Neurosurgery Group (2019 NY Slip Op 03749) Appellate Division, Second Department, 2019Second Department: insurer's fee schedule showing established excess, unrebuttedIn the insurer's de novo action under Insurance Law § 5106 (c), the insurer established prima facie that the amount the provider sought was not in accordance with the workers' compensation fee schedule, and the provider failed to raise a triable issue; summary judgment on that branch should have been granted.
the plaintiff established its prima facie entitlement to judgment as a matter of law on that branch of its motion which was for summary judgment on so much of the complaint, as, in effect, sought a determination that the amount of the benefits sought by the defendant was not in accordance with the workers’ compensation fee schedule
Global Liberty Ins. Co. of N.Y. v Acupuncture Now, P.C. (2019 NY Slip Op 08942) Appellate Division, First Department, 2019First Department: chiropractor rate not mandatory for every licensed acupuncturistInsurers seeking a declaration that licensed acupuncturists may be paid only under the chiropractor schedule did not show that as a matter of law or that the claims exceeded the schedule, and the providers raised an issue of fact whether the physician schedule applies; Great Wall-type holdings do not foreclose the physician schedule in all cases.
In any event, defendants raised an issue of fact as to whether the physician fee schedule should apply.
Rogy Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50732(U)) Appellate Term, Second Department, 2009Insurer must prove the excess; a timely denial is not enoughThe insurer showed it timely denied the claims on the fee schedule ground but did not submit sufficient evidence that the amounts charged exceeded the fee schedule, so the denial of its summary judgment motion was affirmed.
However, defendant did not proffer sufficient evidence to establish as a matter of law that the amounts charged in said claims were in excess of the amounts permitted by the fee schedule
Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467) Appellate Term, Second Department, 2009Licensed acupuncturists may be paid at the chiropractor acupuncture rateAfter a nonjury trial on stipulated facts, the court held as a matter of law that an insurer may use the workers' compensation fee schedule for acupuncture by chiropractors to pay a licensed acupuncturist; since the insurer had paid at that rate, no further reimbursement was due.
we hold, as a matter of law, that an insurer may use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such acupuncture services
Oleg's Acupuncture, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50095(U)) Appellate Term, Second Department, 2018Certified coder's affidavit suffices; counsel's affirmation cannot rebut itA certified medical coder's affidavit established prima facie that the insurer had fully paid the claims under the fee schedule; the provider's attorney affirmation raised no triable issue, and for services after April 1, 2013 no timely denial was needed, so the complaint was dismissed.
Defendant supported its cross motion with an affidavit by its certified medical coder and biller, which affidavit was sufficient to establish, prima facie, that defendant had fully paid the claims in accordance with the fee schedule.
MIA Acupuncture, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 21480) Appellate Term, Second Department, 2011Conclusory 'fee schedule review' statement does not prove the excessA claims examiner's statement that the claims underwent a 'fee schedule review' resulting in a reduction did not establish that the charges exceeded the workers' compensation fee schedule, so the insurer was not entitled to summary judgment on those claims.
This allegation alone was insufficient to establish defendant’s contention that the amounts charged by plaintiff for these acupuncture services exceeded the relevant rates set forth in the workers’ compensation fee schedule
Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co. 61 AD3d 13Cited by 23 candidates: the workers' compensation fee schedule may be judicially noticed (used to decide whether the schedule must be annexed), and Rogy cites it for the insurer's burden; it also held that a fee schedule defense is precluded if not timely raised (pre-2013 precludability, outside this topic).Not in our database.

Authority map

Each circle is a decision on this question, placed by court and date; its colour is the position it took. Lines are citations between them. Select a circle (or find a decision by name) to see its links and summary. The same decisions are listed by court below the map.

Insurer proved the billed amount exceeded the applicable fee scheduleInsurer's proof did not establish the excess as a matter of law; question left for trialCourt finally rejected the fee schedule defense; provider recovers the disputed amountExcess shown for some charges, not for othersRing: rules on the question, but another ground decided the caseContrasted, distinguished or limitedDeclined to follow, questioned, overruled or reversedCited Show ordinary citations

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How the rule was applied, by court

Court	Excess shown	Not established; open	Defense rejected	Split by charge	Total
Court of Appeals	1	0	0	0	1
Appellate Division, First Department	0	2	0	0	2
Appellate Division, Second Department	4	1	1	0	6
Appellate Term, First Department	14	7	3	7	31
Appellate Term, Second Department	132	66	18	22	238
Trial courts in the First Department	7	2	3	0	12
Trial courts in the Second Department	10	17	10	2	39
Trial courts in the Fourth Department	1	0	0	0	1

Decisions (330)

Every decision in our database that rules on this question: highest court first, then by department, newest first. 281 turn on it; the others rule on it alongside a different main ground (marked "also decides"). The one-sentence summaries describe what each court said on this question.

Court of Appeals (1 decision)

Government Empls. Ins. Co. v Avanguard Med. Group, PLLC (2016 NY Slip Op 02473) Court of Appeals, March 31, 2016Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held no-fault insurers need not reimburse office-based surgery facility fees, because no fee schedule provides for them and 11 NYCRR 68.5 covers only professional health services, not facility expenses.

Appellate Division, First Department (2 decisions)

Global Liberty Ins. Co. of N.Y. v Acupuncture Now, P.C. (2019 NY Slip Op 08942) Leading case Appellate Division, First Department, December 12, 2019Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurers did not show as a matter of law that licensed acupuncturists may be paid only at the chiropractor rate or that the claims exceeded the schedule, and the providers raised an issue whether the physician schedule applies.
Matter of Global Liberty Ins. Co. v McMahon (2019 NY Slip Op 03692) Appellate Division, First Department, May 9, 2019Insurer's proof did not establish the excess as a matter of law; question left for trialVacated the award and remanded because the arbitrator wrongly refused to consider CPT Assistant, which is incorporated by reference into the workers' compensation fee schedule through the CPT book.

Appellate Division, Second Department (6 decisions)

Healthplus Surgery Ctr., LLC v American Tr. Ins. Co. (2022 NY Slip Op 02252) Appellate Division, Second Department, April 6, 2022Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's expert affidavit established that the bills exceeded the applicable fee schedule, limiting recovery to the calculated amounts, and the provider raised no triable issue, so the excess was dismissed.
Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 03772) Appellate Division, Second Department, July 8, 2020Insurer's proof did not establish the excess as a matter of law; question left for trialHeld that although the insurer showed the surgical device was not reimbursable under the applicable New Jersey fee schedule, the provider raised a triable issue whether the device qualified for reimbursement under the New Jersey code.
Matter of Hereford Ins. Co. v American Tr. Ins. Co. (2019 NY Slip Op 05778) Appellate Division, Second Department, July 24, 2019Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Confirmed a loss-transfer award granting full recovery despite the respondent insurer's fee schedule challenge to New Jersey services, finding the award had a reasonable hypothesis and was not arbitrary and capricious.
Allstate Ins. Co. v Buffalo Neurosurgery Group (2019 NY Slip Op 03749) Leading case Appellate Division, Second Department, May 15, 2019Insurer proved the billed amount exceeded the applicable fee scheduleIn the insurer's de novo action, held it established that the benefits sought were not in accordance with the fee schedule and the provider failed to raise a triable issue, so summary judgment on that branch was granted.
Government Empls. Ins. Co. v Avanguard Med. Group, PLLC (2015 NY Slip Op 01413) Appellate Division, Second Department, February 18, 2015Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the insurer not required to pay facility fees for office-based surgery because no applicable fee schedule provides for them and the 11 NYCRR 68.5 default provision cannot create a new category of reimbursable fees.
Forrest Chen Acupuncture Servs., P.C. v GEICO Ins. Co. (2008 NY Slip Op 07211) Appellate Division, Second Department, September 30, 2008Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established that no acupuncture fee schedule existed in 2001 and that it properly limited payment to charges for similar procedures under existing schedules, and the provider raised no issue of fact.

Appellate Term, First Department (31 decisions)

Healthy Way Acupuncture PC v Global Liberty Ins. Co. of N.Y. (2018 NY Slip Op 51709(U)) Appellate Term, First Department, November 29, 2018Insurer's proof did not establish the excess as a matter of law; question left for trialHeld summary judgment unavailable because the insurer's conflicting submissions on what it paid and when raised triable issues as to whether the claims were properly denied under the applicable fee schedules.
Lotus Acupuncture PC v Hereford Ins. Co. (2018 NY Slip Op 50057(U)) Appellate Term, First Department, January 18, 2018Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's proof insufficient to establish prima facie that the charges exceeded the governing fee schedule, and its reply arguments left triable issues, so its summary judgment motion was denied.
Easy Care Acupuncture, PC v MVAIC (2017 NY Slip Op 51346(U)) Appellate Term, First Department, October 11, 2017Excess shown for some charges, not for othersHeld the insurer properly paid part of the acupuncture claims under the fee schedule but triable issues remained on claims denied because the maximum payment had already been made for the billed codes.
Acupuncture Approach, P.C. v Tri State Consumer Ins. Co. (2017 NY Slip Op 51170(U)) Appellate Term, First Department, September 19, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialReinstated the CPT 97039 claim, holding the insurer failed to establish prima facie that the service was not reimbursable as a physical medicine modality outside the acupuncturist's specialty, leaving triable issues.
Healthy Way Acupuncture, P.C. v Clarendon Natl. Ins. Co. (2017 NY Slip Op 50345(U)) Appellate Term, First Department, March 24, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's proof insufficient to establish prima facie that the provider's charges exceeded the workers' compensation fee schedule rates, so its summary judgment motion was properly denied.
Easy Care Acupuncture, PC v MVAIC (2016 NY Slip Op 51556(U)) Appellate Term, First Department, October 26, 2016Excess shown for some charges, not for others (also decides)Held the insurer properly paid part of the acupuncture claims under the fee schedule but triable issues remained on claims denied because the maximum payment had already been made for the billed codes.
Urban Well Acupuncture, P.C. v Erie Ins. Co. of N.Y. (2016 NY Slip Op 51302(U)) Appellate Term, First Department, September 19, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established it properly denied the acupuncture charges as exceeding the fee schedule and the provider raised no triable issue on the fee calculation, so the complaint was dismissed.
Urban Well Acupuncture, P.C. v Erie Ins. Co. of N.Y. (2016 NY Slip Op 51300(U)) Appellate Term, First Department, September 19, 2016Excess shown for some charges, not for othersHeld the insurer established the 97813 and 97814 charges exceeded the fee schedule, but triable issues remained whether it properly denied the 99202 initial evaluation claim.

Show all 31 decisions

TC Acupuncture, P.C. v Tri-State Consumer Ins. Co. (2016 NY Slip Op 50978(U)) Appellate Term, First Department, June 27, 2016Excess shown for some charges, not for othersHeld the insurer properly paid part of the claims under the fee schedule, but its licensing objection to CPT 97039 was unpersuasive and its proof did not show the Ground Rule 11 denials were proper, leaving triable issues.
Urban Well Acupuncture, P.C. v Hereford Ins. Co. (2016 NY Slip Op 50606(U)) Appellate Term, First Department, April 18, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established it denied the acupuncture charges as exceeding the fee schedule and the provider raised no triable issue on the fee calculation, so dismissal was affirmed.
Lancer Acupuncture, P.C. v Amica Mut. Ins. Co. (2016 NY Slip Op 50537(U)) Appellate Term, First Department, April 13, 2016Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer's documents left triable issues on whether it properly denied the small claim billed under CPT code 99203 for an initial evaluation, so that claim was reinstated.
Easy Care Acupuncture, PC v 21st Century Indem. Ins. Co. (2015 NY Slip Op 51850(U)) Appellate Term, First Department, December 18, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established it timely and properly denied the acupuncture charges as exceeding the fee schedule and the provider raised no triable issue, so dismissal was affirmed.
Easy Care Acupuncture, P.C. v Nationwide Gen. Ins. Co. (2015 NY Slip Op 51849(U)) Appellate Term, First Department, December 18, 2015Excess shown for some charges, not for othersHeld the insurer established the 97810-97814 charges exceeded the fee schedule, but triable issues remained whether it properly denied the 99202 initial evaluation claim, which was reinstated.
Healthy Way Acupuncture, P.C. v Amica Mut. Ins. Co. (2015 NY Slip Op 51623(U)) Appellate Term, First Department, November 12, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established it denied the acupuncture charges as exceeding the fee schedule and the provider raised no triable issue on the fee calculation, so dismissal was affirmed.
Cliffside Park Imaging & Diagnostic v Travelers Ins. Co. (2015 NY Slip Op 51489(U)) Appellate Term, First Department, October 8, 2015Insurer proved the billed amount exceeded the applicable fee scheduleUpheld partial summary judgment for the insurer, holding it could rely on the New Jersey fee schedule as the prevailing fee for services rendered in New Jersey; objections to the calculation were premature.
Surgicare Surgical Assoc. v National Interstate Ins. Co. (2015 NY Slip Op25338) Appellate Term, First Department, October 8, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld that for surgery performed in New Jersey the insurer properly paid under the New Jersey fee schedule as the prevailing fee under 11 NYCRR 68.6, so the provider could not recover the higher billed amount.
VS Care Acupuncture v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50164(U)) Appellate Term, First Department, February 25, 2015Excess shown for some charges, not for othersHeld the insurer established excess charges for CPT 97810, 97811 and 99203, but triable issues remained for moxibustion and infrared codes because the coder's position that acupuncturists could not be reimbursed under physical medicine codes was unpersuasive.
Karina K. Acupuncture P.C. v State-Wide Ins. Co. (2014 NY Slip Op 51518(U)) Appellate Term, First Department, October 22, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established prima facie that the acupuncture fees exceeded the applicable fee schedule and the provider raised no triable issue on the calculation, so the claim for the unpaid difference was dismissed.
Epic Pain Mgt. & Anesthesia Consultants, LLC v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51391(U)) Appellate Term, First Department, September 16, 2014Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's fee schedule showing insufficient because it ignored 11 NYCRR 68.6, which sets the prevailing fee in the provider's geographic location for out-of-state services, leaving triable issues on the applicable rate.
Okslen Acupuncture P.C. v Travco Ins. Co. (2014 NY Slip Op 51209(U)) Appellate Term, First Department, August 11, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly limited a licensed acupuncturist's reimbursement to the physician acupuncture schedule because counsel's affirmation did not show the services were dissimilar to physicians' acupuncture, so no triable issue on the calculation existed.
Healthy Way Acupuncture P.C. v Metropolitan Prop. & Cas. Ins. Co. (2014 NY Slip Op 51127(U)) Appellate Term, First Department, July 24, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claims representative's affidavit with judicially noticeable fee schedule excerpts sufficed to establish proper calculation of the acupuncture fees, and the provider raised no triable issue, so the complaint was dismissed.
Sunrise Acupuncture PC v Tri-State Consumer Ins. Co. (2014 NY Slip Op 50435(U)) Appellate Term, First Department, March 21, 2014Excess shown for some charges, not for othersFound the insurer properly paid part of the acupuncture claims under the fee schedule, but held its examiner's conclusory assertions that other CPT codes were outside the provider's specialty insufficient, leaving triable issues on those denials.
Karina K. Acupuncture P.C. v MVAIC (2013 NY Slip Op 52127(U)) Appellate Term, First Department, December 13, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld MVAIC established that the acupuncture fees exceeded the applicable workers' compensation fee schedule and the provider raised no triable issue as to the calculation, so the claim for the unpaid difference was dismissed.
Lotus Acupuncture, P.C. v MVAIC (2013 NY Slip Op 51925(U)) Appellate Term, First Department, November 20, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer established that the acupuncture fees exceeded the workers' compensation fee schedule and the provider raised no triable issue on the calculation, so the claim for the difference was dismissed.
Akita Med. Acupuncture, P.C. v Clarendon Ins. Co. (2013 NY Slip Op 51860(U)) Appellate Term, First Department, November 14, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist at the chiropractor acupuncture rate under 11 NYCRR 68.5(b), and since it undisputedly paid that amount in full, no further reimbursement was due.
Devonshire Surgical Facility, LLC v Allstate Ins. Co. (2012 NY Slip Op 52351(U)) Appellate Term, First Department, December 24, 2012Insurer's proof did not establish the excess as a matter of law; question left for trialHeld triable issues remained whether the timely denied amounts properly reflected the provider's surgical facility status or exceeded the governing fee schedule, so the provider's summary judgment motion was denied.
Ashraf Ashour Physical Therapy, P.C. v Interboro Mut. Indem. Ins. Co. (2012 NY Slip Op 50491(U)) Appellate Term, First Department, March 20, 2012Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the provider did not seriously challenge the insurer's showing of compliance with the applicable fee schedules for the remaining claims, so those claims were dismissed.
Natural Acupuncture Health, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 50040(U)) Appellate Term, First Department, January 14, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claims examiner's affidavit and judicially noticed fee schedule excerpts showed the charges exceeded the scheduled rates, and the provider raised no triable issue on interpretation or calculation.
OS Tigris Acupuncture, P.C. v Liberty Mut. Insurance Co. (2008 NY Slip Op 51996(U)) Appellate Term, First Department, October 7, 2008Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held the insurer produced no competent evidence supporting its fee schedule nonconformity defense, so the provider was awarded summary judgment for the full amount.
Bronx Multi Med. Care, P.C. v Kemper Cas. Ins. Co. (2008 NY Slip Op 51928(U)) Appellate Term, First Department, September 24, 2008Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held the insurer submitted no competent evidentiary proof that the charges failed to conform to the workers' compensation fee schedule, and the provider was awarded the full amount claimed.
Continental Med., P.C. v Travelers Indem. Co. (2006 NY Slip Op 50841(U)) Appellate Term, First Department, May 11, 2006Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer failed to demonstrate by competent evidentiary proof that the remaining claims exceeded the fee schedules, and awarded the provider summary judgment for those claims.

Appellate Term, Second Department (238 decisions)

Healthway Med. Care, P.C. v MVAIC (2026 NY Slip Op 50200(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to show prima facie that it properly applied CPT code 95834 to a claim billed under 95831, so summary judgment on that cause of action was properly denied.
Acupuncture Now, P.C. v MVAIC (2026 NY Slip Op 50196(U)) Appellate Term, Second Department, January 23, 2026Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer conclusively established that, under the chiropractor acupuncture schedule applicable before October 1, 2020, the licensed acupuncturist's charges exceeded the schedule by $425.09, and dismissed the claim to that extent.
Acupuncture Now, P.C. v MVAIC (2026 NY Slip Op 50197(U)) Appellate Term, Second Department, January 23, 2026Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer conclusively established that the code 97139 charges exceeded the chiropractor acupuncture fee schedule applicable to licensed acupuncturists by $792.40, and dismissed the claim to that extent.
Harvey Family Chiropractic, Physical Therapy & Acupuncture, PLLC v MVAIC (2025 NY Slip Op 51971(U)) Appellate Term, Second Department, December 5, 2025Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to establish as a matter of law that the claims were improperly billed or exceeded the workers' compensation fee schedule, so summary judgment on that ground was denied.
Metro Pain Specialists, P.C. v Mid-Century Ins. Co. (2023 NY Slip Op 51394(U)) Appellate Term, Second Department, December 8, 2023Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claim representative's and certified coder's affidavits established that the unpaid amount exceeded the fee schedule, and counsel's affirmation without personal knowledge raised no triable issue, so the complaint was dismissed.
Parisien v Tri State Consumers Ins. Co. (2022 NY Slip Op 50920(U)) Appellate Term, Second Department, September 16, 2022Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the charges on the third through tenth claims were improperly billed or exceeded the fee schedule.
Rockland Family Med. Care, P.C. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50766(U)) Appellate Term, Second Department, July 15, 2022Excess shown for some charges, not for othersHeld the claim specialist's and certified coder's affidavits established that the CPT 99212 charges exceeded the fee schedule, but the same affidavits showed $97.14 was owed on the fully denied 99205 claim, so the provider got judgment on it.
UGP Acupuncture, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50612(U)) Appellate Term, Second Department, June 17, 2022Insurer proved the billed amount exceeded the applicable fee scheduleUpheld dismissal of the claims for CPT codes 97810 and 97811 because the insurer had paid them in accordance with the workers' compensation fee schedule for acupuncture performed by chiropractors.

Show all 238 decisions

UGP Acupuncture, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50610(U)) Appellate Term, Second Department, June 17, 2022Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed dismissal of the claims billed under CPT codes 97810 and 97811 because the insurer had paid them under the workers' compensation fee schedule for acupuncture performed by chiropractors; the provider's contrary contention lacked merit for the reasons given in a companion decision.
UGP Acupuncture, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50609(U)) Appellate Term, Second Department, June 17, 2022Insurer proved the billed amount exceeded the applicable fee scheduleUpheld summary judgment dismissing the claims for CPT codes 97810 and 97811 because the insurer had paid them under the workers' compensation fee schedule for acupuncture performed by chiropractors.
Mind & Body Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50603(U)) Appellate Term, Second Department, June 17, 2022Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture services under the chiropractor acupuncture fee schedule and that the claims sought only the difference, and the provider raised no triable issue.
Sutphin Complete Med. Care, P.C. v Tri-State Consumer Ins. Co. (2022 NY Slip Op 50586(U)) Appellate Term, Second Department, June 10, 2022Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to establish that the amount charged on one bill exceeded the workers' compensation fee schedule, so summary judgment on that alternative ground was denied.
Nova Acupuncture, P.C. v Esurance (2022 NY Slip Op 50555(U)) Appellate Term, Second Department, June 3, 2022Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld that, even assuming the chiropractor acupuncture schedule applied, the insurer failed at trial to prove it properly used the schedule's codes to calculate the amounts due, so the provider was awarded the full claim.
Quality Rehab & P.T., P.C. v Tri State Consumers Ins. Co. (2021 NY Slip Op 50730(U)) Appellate Term, Second Department, July 23, 2021Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the provider raised no triable issue in opposition to the insurer's showing that the amounts sought exceeded the workers' compensation fee schedule.
Pavlova v Global Liberty Ins. (2021 NY Slip Op 50726(U)) Appellate Term, Second Department, July 23, 2021Court finally rejected the fee schedule defense; provider recovers the disputed amountAffirmed judgment for the provider after a nonjury trial limited by stipulation to application of the workers' compensation fee schedule, for the reasons stated in a companion decision.
Pavlova v Global Liberty Ins. (2021 NY Slip Op 50725(U)) Appellate Term, Second Department, July 23, 2021Court finally rejected the fee schedule defense; provider recovers the disputed amountAffirmed judgment for the provider after a nonjury trial limited to application of the workers' compensation fee schedule, for the reasons stated in a companion appeal decided the same day.
Pavlova v Global Liberty Ins. (2021 NY Slip Op 50724(U)) Appellate Term, Second Department, July 23, 2021Court finally rejected the fee schedule defense; provider recovers the disputed amountUpheld the trial finding, based on the credibility of the insurer's witness, that the insurer failed to demonstrate the amount sought exceeded the workers' compensation fee schedule.
Jodi Jacobs, D.C., PLLC v Global Liberty Ins. Co. of NY (2021 NY Slip Op 50445(U)) Appellate Term, Second Department, May 14, 2021Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to conclusively establish that the unpaid portion of the claim exceeded the fee schedule, since the schedule alone does not show the codes were properly applied.
Master Cheng Acupuncture, P.C. v Global Liberty Ins. of N.Y. (2020 NY Slip Op 51371(U)) Appellate Term, Second Department, November 13, 2020Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's proof established that it had properly paid the April 17 through May 12, 2014 claims under the workers' compensation fee schedule, and the provider raised no triable issue on the unpaid portion.
S.O.V. Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2020 NY Slip Op 51365(U)) Appellate Term, Second Department, November 13, 2020Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer's moving papers failed to demonstrate as a matter of law that the fees charged exceeded the workers' compensation fee schedule, so its alternative fee schedule ground could not support summary judgment.
Live In Grace Acupuncture, P.C. v GEICO Gen. Ins. Co. (2020 NY Slip Op 51360(U)) Appellate Term, Second Department, November 13, 2020Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the acupuncture services billed under CPT codes 97813 and 97814, rendered after April 1, 2013, in accordance with the workers' compensation fee schedule.
NL Quality Med., P.C. v GEICO Ins. Co. (2020 NY Slip Op 51340(U)) Appellate Term, Second Department, November 6, 2020Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish its fee schedule defense because it relied on unauthenticated, unexplained documents, while an issue of fact remained whether further reimbursement was due.
LVOV Acupuncture, P.C. v Nationwide Ins. Co. (2020 NY Slip Op 51339(U)) Appellate Term, Second Department, November 6, 2020Insurer proved the billed amount exceeded the applicable fee scheduleHeld the certified medical coder's affidavit established the insurer properly used the workers' compensation fee schedule to compute what the provider was owed, and the provider failed to rebut it.
Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2020 NY Slip Op 51338(U)) Appellate Term, Second Department, November 6, 2020Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed dismissal of the unpaid portion of the CPT 97810 and 97811 claims, where the insurer argued it properly paid under the chiropractor fee schedule, for the reasons stated in a companion decision.
Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2020 NY Slip Op 51337(U)) Appellate Term, Second Department, November 6, 2020Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the licensed acupuncturist's 97810 and 97811 claims at the chiropractor acupuncture fee schedule rate, so nothing more was due.
Healing Art Acupuncture, P.C. v GEICO Ins. Co. (2020 NY Slip Op 51336(U)) Appellate Term, Second Department, November 6, 2020Insurer proved the billed amount exceeded the applicable fee scheduleUpheld dismissal of the complaint where the insurer reimbursed the acupuncture services under the fee schedule applicable to chiropractors performing the same services.
S.O.V. Acupuncture, P.C. v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 51004(U)) Appellate Term, Second Department, August 28, 2020Excess shown for some charges, not for othersHeld the insurer fully paid codes 97810, 97811, 99202, 99212 and most 97026 charges at the chiropractor acupuncture rate, but denied judgment on code 90739 because its own coder conceded that amount was owed.
Atlantic Chiropractic, P.C. v Global Liberty Ins. Co. (2020 NY Slip Op 51001(U)) Appellate Term, Second Department, August 28, 2020Insurer's proof did not establish the excess as a matter of law; question left for trialAffirmed denial of the insurer's summary judgment motion because its papers failed to establish as a matter of law that the provider's charges exceeded the fee schedule, leaving that defense as the only issue for trial.
Crystal Acupuncture, P.C. v Travelers Ins. (2019 NY Slip Op 52055(U)) Appellate Term, Second Department, December 13, 2019Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the insurer's proof established that it properly paid two claims under the workers' compensation fee schedule, and the provider's affidavit raised no triable issue.
Blackman v Nationwide Ins. (2019 NY Slip Op 52038(U)) Appellate Term, Second Department, December 13, 2019Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held a triable issue of fact existed on the insurer's fee schedule defense, which needed no preservation for 2015 services, so the provider's summary judgment was vacated.
Metro Pain Specialist, P.C. v Hertz Co. (2019 NY Slip Op 52047(U)) Appellate Term, Second Department, December 13, 2019Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Rejected the insurer's fee schedule argument for summary judgment because its motion had not sought relief on that ground and it offered no evidence, leaving the defense for trial.
Excel Surgery Ctr., LLC v Metropolitan Prop. & Cas. Ins. Co. (2019 NY Slip Op 51843(U)) Appellate Term, Second Department, November 15, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld a certified coder's affidavit established that the insurer fully paid the New Jersey-rendered services under the New Jersey fee schedule, and counsel's affirmation raised no triable issue.
Acupuncture Now, P.C. v Global Liberty Ins. (2019 NY Slip Op 51796(U)) Appellate Term, Second Department, November 1, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture services at the chiropractor acupuncture fee schedule rate, and the provider raised no triable issue.
Quality Comprehensive Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 51734(U)) Appellate Term, Second Department, October 25, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's certified medical coder's affidavit established that any amount above $425.88 per bill exceeded the workers' compensation fee schedule, so the complaint was dismissed to that extent.
Merrick Med., P.C. v A Cent. Ins. Co. (2019 NY Slip Op 51264(U)) Appellate Term, Second Department, August 2, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the litigation examiner's affidavit showed prima facie that the insurer had properly paid the $267.93 claim under the fee schedule, and the provider did not challenge entitlement, so the unpaid portion was dismissed.
Oriental Health Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2019 NY Slip Op 51261(U)) Appellate Term, Second Department, August 2, 2019Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed summary judgment dismissing the complaint on the ground that the amounts sought exceeded the workers' compensation fee schedule, for the reasons given in a companion appeal.
BQE Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2019 NY Slip Op 51260(U)) Appellate Term, Second Department, August 2, 2019Insurer proved the billed amount exceeded the applicable fee scheduleRejected the provider's challenge to reductions made under the chiropractor acupuncture schedule, holding as a matter of law that the insurer could pay a licensed acupuncturist at that rate.
Natural Therapy Acupuncture, P.C. v GEICO Ins. Co. (2019 NY Slip Op 51254(U)) Appellate Term, Second Department, August 2, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the workers' compensation fee schedule to compute what the acupuncture provider was owed and fully paid it, so the unpaid portion was dismissed absent rebuttal.
Apple Massage Therapy, P.C. v 21st Century Ins. Co. (2019 NY Slip Op 51153(U)) Appellate Term, Second Department, July 12, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it properly used the workers' compensation fee schedule to determine the amount owed, so dismissal of the complaint was affirmed.
Masigla v 21st Century Ins. Co. (2019 NY Slip Op 50938(U)) Appellate Term, Second Department, June 7, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's evidence showed the provider was not entitled to payment for four causes of action under the workers' compensation fee schedule, and the provider raised no triable issue, so those claims were dismissed.
BQE Acupuncture, P.C. v GEICO Ins. Co. (2019 NY Slip Op 50743(U)) Appellate Term, Second Department, May 10, 2019Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the acupuncture services at the chiropractor acupuncture rate of the workers' compensation fee schedule, entitling it to dismissal.
GL Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50575(U)) Appellate Term, Second Department, April 12, 2019Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed after trial that the insurer, through its unrebutted certified coder, established it had fully paid the acupuncture codes under the chiropractor fee schedule, limiting recovery to the amount offered for the office visit.
Healing Art Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50574(U)) Appellate Term, Second Department, April 12, 2019Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed dismissal after trial because the insurer established it had fully paid the licensed acupuncturist's services under the chiropractor acupuncture fee schedule, and the provider failed to rebut that showing.
Charles Deng Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2019 NY Slip Op 51042(U)) Appellate Term, Second Department, March 1, 2019Excess shown for some charges, not for othersUpheld the reductions of the acupuncture charges to the chiropractor rate, but held the insurer had not shown entitlement to dismissal of the new-patient visit claim or of a 63-cent shortfall its own coder conceded.
UGP Acupuncture, P.C. v 21st Century Ins. Co. (2018 NY Slip Op 51657(U)) Appellate Term, Second Department, November 16, 2018Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed dismissal because, as a matter of law, the insurer could reduce the licensed acupuncturist's charges using the workers' compensation fee schedule for acupuncture performed by chiropractors.
Acupuncture Now, P.C. v GEICO Ins. Co. (2018 NY Slip Op 51647(U)) Appellate Term, Second Department, November 16, 2018Insurer proved the billed amount exceeded the applicable fee scheduleGranted the insurer summary judgment dismissing the claims for the acupuncture codes on the ground that the amounts sought exceeded the workers' compensation fee schedule, for the reasons given in a companion appeal.
Acupuncture Now, P.C. v GEICO Ins. Co. (2018 NY Slip Op 51645(U)) Appellate Term, Second Department, November 16, 2018Insurer proved the billed amount exceeded the applicable fee scheduleGranted the insurer summary judgment dismissing the claims for the acupuncture codes on the ground that the amounts sought exceeded the workers' compensation fee schedule, for the reasons given in a companion appeal.
Acupuncture Now, P.C. v GEICO Ins. Co. (2018 NY Slip Op 51643(U)) Appellate Term, Second Department, November 16, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid CPT 97810 and 97811 services under the chiropractor acupuncture fee schedule and the provider raised no triable issue, so those claims were dismissed.
Essential Acupuncture Servs., P.C. v GEICO Indem. Co. (2018 NY Slip Op 51600(U)) Appellate Term, Second Department, November 9, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid codes 97810 and 97811 under the fee schedule for acupuncture performed by chiropractors, so the unpaid portions were dismissed.
Jing Luo Acupuncture, P.C. v NY City Tr. Auth. (2018 NY Slip Op 51083(U)) Appellate Term, Second Department, July 6, 2018Excess shown for some charges, not for othersHeld the insurer showed it fully paid acupuncture codes 97811, 97813 and 97814 at the chiropractor rate, but did not establish as a matter of law that the charges under code 99262 exceeded the fee schedule.
Compas Med., P.C. v 21st Century Ins. Co. (2018 NY Slip Op 50773(U)) Appellate Term, Second Department, May 25, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it properly used the workers' compensation fee schedule for pre-April 2013 services and fully paid, so dismissal was affirmed.
Remedial Med. Care, P.C. v Park Ins. Co. (2018 NY Slip Op 50769(U)) Appellate Term, Second Department, May 25, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated, unrebutted, that it had fully paid the bill for one date of service in accordance with the workers' compensation fee schedule.
Oleg's Acupuncture, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50095(U)) Leading case Appellate Term, Second Department, January 19, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's certified coder's affidavit established that the claims were fully paid under the fee schedule, and counsel's affirmation raised no triable issue; no timely denial was needed for post-2013 services.
Precious Acupuncture Care, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50042(U)) Appellate Term, Second Department, January 12, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's certified coder's affidavit established that the claims were fully paid under the fee schedule, counsel's affirmation raised no triable issue, and the defense needed no timely denial for post-2013 services.
Z. M. S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51891(U)) Appellate Term, Second Department, December 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated, without rebuttal, that it had fully paid the acupuncture codes under the chiropractor acupuncture fee schedule, a defense not subject to preclusion for post-April 1, 2013 services.
Charles Deng Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51887(U)) Appellate Term, Second Department, December 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed, unrebutted, that it fully paid the licensed acupuncturist's claims at the chiropractor acupuncture rate under the workers' compensation fee schedule, so those claims were dismissed.
V.S. Care Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51881(U)) Appellate Term, Second Department, December 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer made a prima facie showing that the amounts sought exceeded the applicable fee schedule and the provider offered no admissible evidence raising a triable issue, so those claims were dismissed.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51864(U)) Appellate Term, Second Department, December 22, 2017Excess shown for some charges, not for othersHeld the insurer established full payment under the fee schedule for CPT codes 97811, 97813 and 97814 but left the 97810 charges for trial, where fee schedule application was the only issue.
Oleg's Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51863(U)) Appellate Term, Second Department, December 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid CPT 97813 and 97814 services under the chiropractor acupuncture fee schedule and the provider raised no triable issue, so those claims were dismissed.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51862(U)) Appellate Term, Second Department, December 22, 2017Excess shown for some charges, not for othersHeld the insurer established full payment under the fee schedule for CPT codes 97811, 97813 and 97814 but left the 97810 charges for trial, where fee schedule application was the only issue.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51861(U)) Appellate Term, Second Department, December 22, 2017Excess shown for some charges, not for othersHeld the insurer established full payment under the fee schedule for CPT codes 97811, 97813 and 97814 but left the 97810 charges for trial, where fee schedule application was the only issue.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51860(U)) Appellate Term, Second Department, December 22, 2017Excess shown for some charges, not for othersHeld the insurer proved full payment at the chiropractor acupuncture rate for CPT codes 97811, 97813 and 97814, but not for 97810 because it did not explain its apparent recoding of those services.
GBI Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51832(U)) Appellate Term, Second Department, December 19, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly reduced licensed acupuncturist charges to the chiropractor acupuncture rate under the workers' compensation fee schedule, so dismissal of those claims was affirmed.
Acupuncture Now, P.C. v GEICO Ins. Co. (2017 NY Slip Op 51809(U)) Appellate Term, Second Department, December 19, 2017Insurer proved the billed amount exceeded the applicable fee scheduleRejected the provider's challenge to the insurer's application of the workers' compensation fee schedule, affirming dismissal of the claims denied on that ground.
Adelaida Physical Therapy, P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51808(U)) Appellate Term, Second Department, December 19, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the physical therapy charges exceeded the fee schedule because it did not show it used the correct conversion factor.
Healthway Med. Care, P.C. v Global Liberty Ins. (2017 NY Slip Op 51807(U)) Appellate Term, Second Department, December 19, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish its defense that the fees charged on the third cause of action exceeded the fee schedule, so its summary judgment motion was denied.
Faith Acupuncture, P.C. v Global Liberty Ins. (2017 NY Slip Op 51806(U)) Appellate Term, Second Department, December 19, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the fees charged exceeded the workers' compensation fee schedule, so summary judgment on those causes of action was denied.
Precious Acupuncture Care, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51803(U)) Appellate Term, Second Department, December 19, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's unrebutted proof showed it fully paid the CPT 97813 and 97814 charges at the fee schedule rate for acupuncture performed by chiropractors, so those claims were dismissed.
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2017 NY Slip Op 51792(U)) Appellate Term, Second Department, December 19, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it properly used the workers' compensation fee schedule and fully paid for the services, so dismissal was affirmed.
Jamaica Dedicated Med. Care, P.C. v Tri State Consumer Ins. Co. (2017 NY Slip Op 51790(U)) Appellate Term, Second Department, December 19, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that it had properly paid the remaining claims under the workers' compensation fee schedule, so its cross motion was properly denied.
Renelique v American Tr. Ins. Co. (2017 NY Slip Op 51759(U)) Appellate Term, Second Department, December 15, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not demonstrate as a matter of law that the conceded $267.79 fully compensated the provider under the workers' compensation fee schedule, so its cross motion dismissing the balance was denied.
Adelaida M. Laga, P.T. v GEICO Ins. Co. (2017 NY Slip Op 51715(U)) Appellate Term, Second Department, December 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer's papers did not establish as a matter of law that the fees charged exceeded the workers' compensation fee schedule amounts, so its cross motion was properly denied.
Adelaida M. Laga, Pt v GEICO Ins. Co. (2017 NY Slip Op 51713(U)) Appellate Term, Second Department, December 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish its fee schedule defense as a matter of law because it did not show it used the correct conversion factor or properly applied Ground Rule 11.
AVM Chiropractic, P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51708(U)) Appellate Term, Second Department, December 8, 2017Excess shown for some charges, not for othersHeld the insurer proved full payment under the fee schedule for three claims, but for the remaining claims did not show it had properly reduced them under the workers' compensation Ground Rules, so those branches were denied and the CPLR 3212 (g) findings vacated.
Charles Deng Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51460(U)) Appellate Term, Second Department, October 27, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid CPT 97810 and 97811 at the chiropractor acupuncture rate and rejected the challenge to the fee-schedule reduction of the 99203 charge, so nothing more was due.
Acupuncture Approach, P.C. v NY Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51455(U)) Appellate Term, Second Department, October 27, 2017Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Rejected the provider's challenge to the reduction of the amount in controversy on two claims under the fee schedule, while the defense on three other claims failed only because the insurer did not show timely denials.
Charles Deng Acupuncture, P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51252(U)) Appellate Term, Second Department, September 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleUpheld dismissal of the CPT 97810 and 97811 claims because an insurer may, as a matter of law, pay a licensed acupuncturist under the chiropractor acupuncture fee schedule, as the insurer had done.
AL Acupuncture, P.C. v Geico Ins. Co. (2017 NY Slip Op 51249(U)) Appellate Term, Second Department, September 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture claims under the fee schedule rate for acupuncture by chiropractors; the provider did not rebut this, so those claims were dismissed.
Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51239(U)) Appellate Term, Second Department, September 22, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not demonstrate as a matter of law that it had fully paid the sixth and seventh causes of action under the workers' compensation fee schedule, so its cross motion on them was denied.
GBI Acupuncture, P.C. v GEICO Ins. Co. (2017 NY Slip Op 51237(U)) Appellate Term, Second Department, September 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleRejected the provider's challenge to the insurer's application of the workers' compensation fee schedule, affirming dismissal of the claims denied on that ground.
Compas Med., P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51228(U)) Appellate Term, Second Department, September 22, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's proof showed it had fully paid the code 64550 services under the workers' compensation fee schedule and the provider did not rebut it, so the first and fifth causes of action stayed dismissed.
Island Life Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51157(U)) Appellate Term, Second Department, September 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's motion papers failed to establish as a matter of law that the provider's charges exceeded the workers' compensation fee schedule, so summary judgment for the insurer was reversed.
Acupuncture Now, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51154(U)) Appellate Term, Second Department, September 8, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's reductions to the chiropractor acupuncture rate were proper because an insurer may, as a matter of law, pay a licensed acupuncturist under that schedule, so the claims were dismissed.
Lynbrook Pt & Ot, PLLC v Foremost Ins. Co. (2017 NY Slip Op 51146(U)) Appellate Term, Second Department, September 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld a triable issue of fact existed on the insurer's application of Ground Rule 11 of the fee schedule to the physical therapy claims, so summary judgment for the insurer was denied.
Culex Acupuncture, P.C. v 21st Century Indem. Ins. Co. (2017 NY Slip Op 51145(U)) Appellate Term, Second Department, September 8, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the acupuncture claims at the chiropractor rate even though it paid other claims at the medical doctor rate without explanation, and affirmed dismissal of those claims.
GBI Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51143(U)) Appellate Term, Second Department, September 8, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's reductions to the chiropractor acupuncture rate were proper because an insurer may, as a matter of law, pay a licensed acupuncturist under that schedule, so dismissal was affirmed.
Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51142(U)) Appellate Term, Second Department, September 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not demonstrate as a matter of law that it had fully paid the claim under the workers' compensation fee schedule, so dismissal of the first cause of action was reversed.
Renelique v Allstate Ins. Co. (2017 NY Slip Op 51141(U)) Appellate Term, Second Department, September 8, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed, unrebutted, that it properly applied the fee schedule to calculate the amount due for CPT code 20553, so dismissal of the complaint was affirmed.
Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51138(U)) Appellate Term, Second Department, September 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's motion papers failed to establish as a matter of law that the provider's fees for the second cause of action exceeded the workers' compensation fee schedule.
Charles Deng Acupuncture, P.C. v ELRAC, Inc. (2017 NY Slip Op 51149(U)) Appellate Term, Second Department, September 8, 2017Insurer proved the billed amount exceeded the applicable fee scheduleUpheld dismissal of the acupuncture codes because the insurer may, as a matter of law, pay a licensed acupuncturist at the chiropractor acupuncture fee schedule rate, which it had applied.
K.O. Med., P.C. v Mercury Cas. Co. (2017 NY Slip Op 51158(U)) Appellate Term, Second Department, September 8, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not demonstrate that Ground Rule 11 of the fee schedule was appropriately applied to the remaining claims, so its summary judgment motion on them was properly denied.
Jaga Med. Servs., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50954(U)) Appellate Term, Second Department, July 21, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's professional coder's affidavit established that it properly used the workers' compensation fee schedule to determine the amounts due, so the claims for the unpaid portions were dismissed.
Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 50946(U)) Appellate Term, Second Department, July 21, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the professional coder's affidavit established that the insurer properly applied the workers' compensation fee schedule to the services at issue, and the provider raised no triable issue.
Natural Therapy Acupuncture, P.C. v Nationwide Ins. (2017 NY Slip Op 50943(U)) Appellate Term, Second Department, July 21, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the acupuncture services at the chiropractor acupuncture rate of the workers' compensation fee schedule, entitling it to dismissal.
Gentle Acupuncture, P.C. v Tri-State Consumer Ins. Co. (2017 NY Slip Op 50706(U)) Appellate Term, Second Department, May 23, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not establish its fee schedule defense prima facie because it submitted no expert affidavit explaining its interpretation of the fee schedule.
2 & 9 Acupuncture, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50599(U)) Appellate Term, Second Department, April 27, 2017Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to show prima facie that it properly paid the CPT 97026 and 97016 charges under the fee schedule, so summary judgment dismissing those claims was reversed.
Spineisland for Chiropractic, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50598(U)) Appellate Term, Second Department, April 27, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed prima facie that it properly recoded services billed under CPT 95831 to CPT 95833, and the provider raised no triable issue, so dismissal of that claim was affirmed.
Dynasty Med. Care, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50597(U)) Appellate Term, Second Department, April 27, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed prima facie that it properly applied the fee schedule, and the provider raised no triable issue, so dismissal of the complaint was affirmed.
Thomas Dow, D.C., P.C. v New York Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 50495(U)) Appellate Term, Second Department, April 13, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer made a prima facie showing that the amount sought exceeded the applicable fee schedules and the provider's counsel affirmation and medical-necessity affidavit raised no triable issue.
Acuhealth Acupuncture, P.C. v Ameriprise Ins. Co. (2017 NY Slip Op 50119(U)) Appellate Term, Second Department, January 20, 2017Insurer proved the billed amount exceeded the applicable fee scheduleHeld the litigation examiner's affidavit and exhibits established that the insurer had fully paid the acupuncture services under the workers' compensation fee schedules, and the provider raised no triable issue.
Renelique v American Tr. Ins. Co. (2016 NY Slip Op 51526(U)) Appellate Term, Second Department, October 13, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's examiner affidavit showed it calculated the fees by relative value times conversion factor, and the provider's claim that CPT 20553 was a 'by report' code did not rebut it.
High Quality Med. Supplies, Inc. v Mercury Ins. Group (2016 NY Slip Op 51444(U)) Appellate Term, Second Department, October 5, 2016Court finally rejected the fee schedule defense; provider recovers the disputed amountRejected the insurer's argument that durable medical equipment not listed in the adopted Medicaid DME fee schedule is not compensable, because 11 NYCRR 68.5 governs reimbursement for items not set forth in the fee schedules.
Gl Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51419(U)) Appellate Term, Second Department, September 27, 2016Excess shown for some charges, not for othersHeld the insurer showed full payment of CPT 97810 and 97811 under the fee schedule, but its evidence was insufficient to dismiss the claim for the initial acupuncture visit.
Laga v Foremost Signature Ins. Co. (2016 NY Slip Op 51418(U)) Appellate Term, Second Department, September 27, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the fees charged exceeded the workers' compensation fee schedule, so its summary judgment motion should have been denied.
Liberty Chiropractic, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 51409(U)) Appellate Term, Second Department, September 27, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish its fee schedule defense because it did not show it used the correct conversion factor, and its unauthenticated Ground Rule 11 documents showed the other provider billed only three units.
NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51362(U)) Appellate Term, Second Department, September 19, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it fully paid the licensed acupuncturist under the workers' compensation fee schedule for acupuncture performed by chiropractors, which an insurer may use as a matter of law.
Sama Physical Therapy, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51359(U)) Appellate Term, Second Department, September 19, 2016Excess shown for some charges, not for othersHeld the insurer properly recoded CPT 97799 as 97140 and reduced those charges, but failed to show Ground Rule 11's eight-unit cap was properly applied to the first three causes of action.
TAM Med. Supply Corp. v 21st Century Ins. Co. (2016 NY Slip Op 51358(U)) Appellate Term, Second Department, September 19, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's papers failed to establish as a matter of law that the supply charges exceeded the workers' compensation fee schedule, so it was not entitled to summary judgment.
Charles Deng Acupuncture, P.C. v Farmington Cas. Co. (2016 NY Slip Op 51326(U)) Appellate Term, Second Department, September 15, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's proof established that it had fully paid the provider for the services at issue in accordance with the workers' compensation fee schedule, so dismissal was affirmed.
Al Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51245(U)) Appellate Term, Second Department, August 18, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the acupuncture claim under the fee schedule for acupuncture by chiropractors, so nothing more was due and medical necessity was moot.
Renelique v Tri State Consumers Ins. Co. (2016 NY Slip Op 50867(U)) Appellate Term, Second Department, June 3, 2016Insurer proved the billed amount exceeded the applicable fee scheduleUpheld summary judgment for the insurer on its showing that it had fully paid the provider under the workers' compensation fee schedule, for the reasons given in the companion appeal.
Renelique v Tri State Consumers Ins. Co. (2016 NY Slip Op 50866(U)) Appellate Term, Second Department, June 3, 2016Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed summary judgment for the insurer, which had argued it fully paid under the fee schedule. The court rejected the preclusion argument and refused to consider the provider's calculation challenge because it was raised for the first time on appeal.
LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50862(U)) Appellate Term, Second Department, June 3, 2016Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the provider's affidavits raised triable issues of fact on whether the amounts sought exceeded the workers' compensation fee schedule, so the insurer's alternative branch was denied.
Harvard Med., P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50860(U)) Appellate Term, Second Department, June 3, 2016Insurer proved the billed amount exceeded the applicable fee scheduleUpheld summary judgment for the insurer on its showing that it had fully paid the provider under the workers' compensation fee schedule, for the reasons given in the companion appeal.
GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U)) Appellate Term, Second Department, June 3, 2016Insurer proved the billed amount exceeded the applicable fee scheduleUpheld summary judgment for the insurer on its showing that it had fully paid the acupuncture provider under the workers' compensation fee schedule, for the reasons given in the companion appeal.
New Age Acupuncture, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 50737(U)) Appellate Term, Second Department, May 5, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer's moving papers failed to show prima facie entitlement to dismissal of the charges billed under CPT code 97026, citing the rule that an insurer must prove the amounts exceeded the fee schedule.
Natural Therapy Acupuncture, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50389(U)) Appellate Term, Second Department, March 18, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the no-fault examiner's affidavit and exhibits established the insurer fully paid the acupuncture provider under the workers' compensation fee schedule, and the provider raised no triable issue.
Compas Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50376(U)) Appellate Term, Second Department, March 17, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the litigation examiner's affidavit showed prima facie that the claims were properly reduced under the fee schedule, but the provider's opposition raised a triable issue on whether the reductions were proper.
Performance Plus Med., P.C. v Nationwide Ins. (2016 NY Slip Op 50366(U)) Appellate Term, Second Department, March 16, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claims representative's affidavit established prima facie that the first cause of action's claims were properly denied under the workers' compensation fee schedule, and the provider raised no triable issue.
GBI Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 50329(U)) Appellate Term, Second Department, March 15, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture provider under the workers' compensation fee schedule applicable to chiropractors performing acupuncture, so its fee schedule reductions were proper.
Acupuncture Healthcare Plaza I, P.C. v Truck Ins. Exch. (2016 NY Slip Op 50309(U)) Appellate Term, Second Department, March 11, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the acupuncture services at the chiropractor acupuncture rate of the workers' compensation fee schedule, entitling it to dismissal.
Compas Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50307(U)) Appellate Term, Second Department, March 11, 2016Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to establish as a matter of law that the fees charged exceeded the workers' compensation fee schedule or that there was duplicate billing.
Acupuncture Healthcare Plaza I, P.C. v 21st Century Ins. Co. (2015 NY Slip Op 51716(U)) Appellate Term, Second Department, November 20, 2015Insurer proved the billed amount exceeded the applicable fee scheduleRejected the provider's challenge and held the insurer fully paid the services at the workers' compensation fee schedule rate for acupuncture performed by chiropractors.
Natural Therapy Acupuncture, P.C. v Travelers Ins. Co. (2015 NY Slip Op 51713(U)) Appellate Term, Second Department, November 20, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer, after applying the deductible, fully paid the services under the chiropractor acupuncture fee schedule, so dismissal was affirmed.
GL Acupuncture, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51698(U)) Appellate Term, Second Department, November 19, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the services under the chiropractor acupuncture fee schedule, so dismissal was affirmed.
New Way Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51627(U)) Appellate Term, Second Department, November 9, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claims representative's affidavit established prima facie that the supply claims were properly denied under the workers' compensation fee schedule, and the provider failed to raise a triable issue.
Neomy Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51237(U)) Appellate Term, Second Department, August 6, 2015Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the acupuncture provider's fees exceeded the workers' compensation fee schedule, so its motion was properly denied.
GBI Acupuncture, P.C. v 21st Century Ins. Co. (2015 NY Slip Op 51235(U)) Appellate Term, Second Department, August 6, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's certified coder affidavit established that it properly used the workers' compensation fee schedule to compute the amount due, and the provider raised no triable issue, so the complaint was dismissed.
Mind & Body Acupuncture, P.C. v Elrac, Inc. (2015 NY Slip Op 51219(U)) Appellate Term, Second Department, August 5, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture codes under the fee schedule, and that the same-day initial evaluation was not payable because the higher treatment fee was the only fee due.
Nova Acupuncture, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50914(U)) Appellate Term, Second Department, June 16, 2015Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer, while showing it made payments, failed to establish prima facie that its reimbursements equaled or exceeded the chiropractor acupuncture rate, leaving a triable issue; other claims were precluded by untimely denials.
Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U)) Appellate Term, Second Department, May 18, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's affidavit showed prima facie that Ground Rules 3 and 5 were properly applied and that recoding CPT 20553 as 20552 properly yielded the reduced amount it paid.
Meridian Acupuncture Care, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50681(U)) Appellate Term, Second Department, May 1, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the provider for the treatment in accordance with the workers' compensation fee schedule, so those claims were dismissed.
Healing Art Acupuncture, P.C. v Maya Assur. Co. (2015 NY Slip Op 50387(U)) Appellate Term, Second Department, March 13, 2015Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the fee charged exceeded the workers' compensation fee schedule, so it was not entitled to summary judgment on that claim.
Gutierrez v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50379(U)) Appellate Term, Second Department, March 12, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's affidavits showed Ground Rules 3 and 5 were properly applied and CPT 20552 properly used, so it had paid more than the fee schedule required and the provider did not rebut this.
Healing Art Acupuncture, P.C. v Amica Mut. Ins. Co. (2015 NY Slip Op 50078(U)) Appellate Term, Second Department, January 15, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the vendor fee schedule adjuster's affidavit established that the insurer properly applied the chiropractor acupuncture fee schedule and fully paid, and the provider raised no triable issue.
Health Needles Acupuncture, P.C. v GEICO Ins. Co. (2014 NY Slip Op 51864(U)) Appellate Term, Second Department, December 19, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the licensed acupuncturist under the workers' compensation fee schedule for acupuncture performed by chiropractors, so the remaining claims were properly dismissed.
Compas Med., P.C. v GEICO Ins. Co. (2014 NY Slip Op 51857(U)) Appellate Term, Second Department, December 19, 2014Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to proffer sufficient evidence that the claim was improperly billed or exceeded the fee schedule, so the lower court's grant of its cross motion on the unpaid balance was reversed.
Health Needles Acupuncture, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51831(U)) Appellate Term, Second Department, December 17, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the acupuncture services at the workers' compensation fee schedule rate for acupuncture performed by chiropractors, so nothing more was due on those claims.
Compas Med., P.C. v Nationwide Ins. (2014 NY Slip Op 51826(U)) Appellate Term, Second Department, December 17, 2014Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the fees charged on two claims exceeded the workers' compensation fee schedule, leaving a triable issue of fact.
Parkview Med. & Surgical, P.C. v Geico Gen. Ins. Co. (2014 NY Slip Op 51822(U)) Appellate Term, Second Department, December 17, 2014Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the claims examiner's affidavit insufficient to establish that the fee-schedule-denied charges exceeded the workers' compensation fee schedule, so summary judgment on those claims was denied.
LMS Acupuncture, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51799(U)) Appellate Term, Second Department, December 17, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture claims under the chiropractor acupuncture fee schedule, and the provider raised no triable issue in response.
Compas Med., P.C. v Geico Ins. Co. (2014 NY Slip Op 51259(U)) Appellate Term, Second Department, August 8, 2014Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law its entitlement to dismissal of the claims denied as exceeding the workers' compensation fee schedule, leaving the defense for trial.
Triumph Assoc. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50875(U)) Appellate Term, Second Department, May 22, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it paid the full fee schedule amount on one claim and properly denied another under Physical Medicine Ground Rule 11, and the provider raised no triable issue.
SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U)) Appellate Term, Second Department, April 7, 2014Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the claims representative's affidavit and the Medicaid DME fee schedule adopted for workers' compensation showed the insurer's payment for code E0190 was the full scheduled amount, below what was billed.
Rogy Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 50629(U)) Appellate Term, Second Department, April 7, 2014Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer submitted no proof that it had paid one claim in compliance with the workers' compensation fee schedule, so summary judgment on that claim was properly denied.
LMS Acupuncture, P.C. v Geico Ins. Co. (2014 NY Slip Op 50416(U)) Appellate Term, Second Department, March 11, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the disputed acupuncture claims under the fee schedule for acupuncture performed by chiropractors, and counsel's affirmation raised no triable issue, so those claims were dismissed.
Ema Acupuncture, P.C. v Geico Ins. Co. (2014 NY Slip Op 50415(U)) Appellate Term, Second Department, March 11, 2014Excess shown for some charges, not for othersHeld the insurer showed full payment at the chiropractor acupuncture rate for the session claims, but raised no issue defeating the initial-visit claim billed under code 99205, which was awarded to the provider.
Martin Plutno v Travelers Ins. Co. (2014 NY Slip Op 50412(U)) Appellate Term, Second Department, March 11, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's employee affidavit established that it paid part of the claim and denied the remaining $101.10 as exceeding the fee schedule, and the provider raised no triable issue, so that portion was dismissed.
Bay Med. P.C. v Geico Ins. Co. (2013 NY Slip Op 52084(U)) Appellate Term, Second Department, December 9, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's claims employee's affidavit established that seven claims had been paid in accordance with the applicable New Jersey fee schedule within 60 days, and the provider did not rebut it, so those claims were dismissed.
20th Ave Acupuncture, P.C. v MVAIC (2013 NY Slip Op 51741(U)) Appellate Term, Second Department, October 10, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the remaining acupuncture services in accordance with the workers' compensation fee schedule, so those claims were dismissed.
Gl Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 51748(U)) Appellate Term, Second Department, October 8, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the claims representative's affidavit established the insurer properly used the chiropractor acupuncture fee schedule and fully paid, and the provider's attorney affirmation raised no triable issue.
Shara Acupuncture, P.C. v Allstate Ins. Co. (2013 NY Slip Op 51731(U)) Appellate Term, Second Department, October 8, 2013Excess shown for some charges, not for othersHeld the insurer fully paid the acupuncture codes 97810 and 97811 at the chiropractor acupuncture rate, but had not addressed the initial evaluation billed under 99203, so dismissal of that charge was reversed.
Flushing Traditional Acupuncture, P.C. v Geico Ins. Co. (2013 NY Slip Op 51538(U)) Appellate Term, Second Department, September 13, 2013Excess shown for some charges, not for othersHeld the insurer properly applied the chiropractor acupuncture schedule to codes 97813 and 97814, but, having failed to address the initial evaluation billed under 99202, it was not entitled to dismissal of that charge.
Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co. (2013 NY Slip Op 50904(U)) Appellate Term, Second Department, May 22, 2013Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to establish as a matter of law that the fee charged on one claim exceeded the workers' compensation fee schedule, so summary judgment on it was denied.
Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50752(U)) Appellate Term, Second Department, May 6, 2013Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the claims examiner's affidavit failed to substantiate the fee schedule defense underlying one denial, so the insurer was not entitled to summary judgment.
Broad St. Acupuncture, P.C. v American Tr. Ins. Co. (2013 NY Slip Op 50453(U)) Appellate Term, Second Department, March 20, 2013Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held that triable issues remained on the unpaid, fee-schedule-denied portions of two partially paid claims, so neither party obtained summary judgment on them.
Apple Tree Acupuncture, P.C. v Allstate Ins. Co. (2013 NY Slip Op 50413(U)) Appellate Term, Second Department, March 15, 2013Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that its payment was the maximum allowed under the chiropractor acupuncture fee schedule and that it properly denied the balance, so its cross motion was denied.
Shara Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50255(U)) Appellate Term, Second Department, February 19, 2013Insurer's proof did not establish the excess as a matter of law; question left for trialHeld triable issues of fact existed as to whether the insurer had fully paid the acupuncture claims in accordance with the workers' compensation fee schedule, so its summary judgment motion was denied.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 50199(U)) Appellate Term, Second Department, February 11, 2013Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to conclusively establish that the fees on one claim exceeded the workers' compensation fee schedule, so its cross motion was denied as to that claim and the dismissal of that claim was vacated.
Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50196(U)) Appellate Term, Second Department, February 11, 2013Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to proffer sufficient evidence that two claims and a $27.88 balance were improperly billed or exceeded the fee schedule, so its cross motion on those claims was denied.
RAZ Acupuncture, P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51826(U)) Appellate Term, Second Department, September 13, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the acupuncture services billed under code 97810 in accordance with the workers' compensation fee schedule, so dismissal of those claims was affirmed.
Ying E. Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51805(U)) Appellate Term, Second Department, September 13, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's affidavit established that it properly used the workers' compensation fee schedule for acupuncture by chiropractors to compute the amount due, so the provider's summary judgment motion was denied.
Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51772(U)) Appellate Term, Second Department, September 5, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the acupuncture services under the fee schedule for acupuncture performed by chiropractors, so those claims were dismissed.
Raz Acupuncture, P.C. v Geico Gen. Ins. Co. (2012 NY Slip Op 51716(U)) Appellate Term, Second Department, August 31, 2012Insurer proved the billed amount exceeded the applicable fee scheduleRejected the provider's argument that the insurer failed to show full payment under the fee schedule and affirmed dismissal of the acupuncture claims timely denied on fee schedule grounds.
Apple Tree Acupuncture, P.C. v Progressive Northeastern Ins. Co. (2012 NY Slip Op 51710(U)) Appellate Term, Second Department, August 31, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the acupuncture claims, some at the chiropractor rate permitted as a matter of law and others at the higher physician rate, so the complaint was properly dismissed.
Acupuncture Works, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 51654(U)) Appellate Term, Second Department, August 24, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the amount due under the fee schedule for acupuncture services rendered by a chiropractor.
Essential Acupuncture Servs., P.C. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51623(U)) Appellate Term, Second Department, August 7, 2012Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to conclusively establish that the fees charged on the remaining claims exceeded the fee schedule, though its proof raised a triable issue defeating the provider's motion on one claim.
Gaba Med., P.C. v Progressive Specialty Ins. Co. (2012 NY Slip Op 51448(U)) Appellate Term, Second Department, July 25, 2012Court finally rejected the fee schedule defense; provider recovers the disputed amountWithout deciding whether the insurer could recode the services to time-based code 97750, held its payment for only one time unit unwarranted because it had no factual basis, the insurer never having requested verification of time spent, and granted the provider summary judgment.
Natural Therapy Acupuncture, P.C. v Interboro Ins. Co. (2012 NY Slip Op 51350(U)) Appellate Term, Second Department, July 13, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed the amounts sought exceeded the workers' compensation fee schedule and that it had fully paid the services under the schedule, apart from a properly denied $200 deductible.
W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co. (2012 NY Slip Op 51335(U)) Appellate Term, Second Department, July 12, 2012Excess shown for some charges, not for othersHeld the insurer showed full payment at the chiropractor rate for the 97810 claims and the reduced-paid 97811 claims, but not for the fully denied 97811 claims, absent an expert explaining its inconsistent reading of the schedule.
Olga Bard Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51292(U)) Appellate Term, Second Department, June 28, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's affidavits established that it fully paid the CPT 97810 and 97811 acupuncture claims in accordance with the workers' compensation fee schedule, so those claims were dismissed.
Megacure Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51291(U)) Appellate Term, Second Department, June 28, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it had fully paid the acupuncture services under the fee schedule for acupuncture performed by chiropractors.
Gentle Care Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51290(U)) Appellate Term, Second Department, June 28, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the amount due under the fee schedule for acupuncture by chiropractors, so those claims were dismissed.
Oriental World Acupuncture, P.C. v GEICO (2012 NY Slip Op 51062(U)) Appellate Term, Second Department, June 11, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's employee affidavit demonstrated that it had fully paid the acupuncture services in accordance with the workers' compensation fee schedule, warranting dismissal of the complaint.
Eastern Star Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51010(U)) Appellate Term, Second Department, May 14, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the fee schedule for acupuncture by chiropractors and had undisputedly paid the full amount due before suit.
Raz Acupuncture, P.C. v Nationwide Mut. Ins. Co. (2012 NY Slip Op 50871(U)) Appellate Term, Second Department, May 11, 2012Insurer proved the billed amount exceeded the applicable fee scheduleAffirmed dismissal of the acupuncture claims, rejecting the provider's argument that the insurer failed to show it had fully paid the services in accordance with the workers' compensation fee schedule.
Raz Acupuncture, P.C. v New S. Ins. Co. (2012 NY Slip Op 50865(U)) Appellate Term, Second Department, May 11, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the provider in accordance with the workers' compensation fee schedule, so dismissal of the causes of action for the unpaid portions was proper.
Perfect Point Acupuncture, P.C. v Clarendon Ins. Co. (2012 NY Slip Op 50399(U)) Appellate Term, Second Department, March 5, 2012Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the claims examiner's affidavit insufficient to establish that the acupuncture charges, including the initial visit, exceeded the applicable fee schedule rates, so the insurer's summary judgment motion was properly denied.
MIA Acupuncture, P.C. v Integon Gen. Ins. Corp. (2012 NY Slip Op 50393(U)) Appellate Term, Second Department, March 2, 2012Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid for the acupuncture services in accordance with the workers' compensation fee schedule, so the complaint was dismissed.
Raz Acupuncture, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 50305(U)) Appellate Term, Second Department, February 14, 2012Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer did not proffer sufficient evidence to dismiss the initial consultation claim and did not establish as a matter of law that the acupuncture charges exceeded the fee schedule, so its cross motion on those claims was properly denied.
MIA Acupuncture, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 21480) Leading case Appellate Term, Second Department, December 29, 2011Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the claims examiner's bare statement that the claims underwent a fee schedule review resulting in a reduction insufficient to establish that the charges exceeded the workers' compensation fee schedule rates.
WJJ Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 52377(U)) Appellate Term, Second Department, December 23, 2011Excess shown for some charges, not for othersHeld the insurer fully paid CPT 97813 acupuncture at the chiropractor rate, dismissing those claims, but offered no evidence that the initial visit charge under 99204 exceeded the schedule, leaving the provider's award on it.
Liu Yong, Acupuncture v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 52375(U)) Appellate Term, Second Department, December 23, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer demonstrated it had fully paid the timely-denied claims in accordance with the workers' compensation fee schedule, so those claims were dismissed.
W.H.O. Acupuncture, P.C. v National Cont. Ins. Co. (2011 NY Slip Op 52370(U)) Appellate Term, Second Department, December 23, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid the acupuncture codes 97810 and 97811 by using the chiropractor acupuncture fee schedule, and the provider raised no triable issue.
Eastern Star Acupuncture, P.C. v American Tr. Ins. Co. (2011 NY Slip Op 52205(U)) Appellate Term, Second Department, December 5, 2011Insurer's proof did not establish the excess as a matter of law; question left for trialHeld an issue of fact existed whether the partially paid claims exceeded the workers' compensation fee schedule, so the provider was not entitled to summary judgment on them.
Megacure Acupuncture, P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52199(U)) Appellate Term, Second Department, November 30, 2011Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish that the acupuncture charges exceeded the fee schedule because it did not annex the schedule or give the notice needed for judicial notice under CPLR 4511.
Crotona Hgts. Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51859(U)) Appellate Term, Second Department, October 12, 2011Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer not entitled to dismissal of the office-visit claim because it failed to substantiate its assertion that its reduced partial payment was made at the proper fee schedule rate.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2011 NY Slip Op 51856(U)) Appellate Term, Second Department, October 12, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the affidavit established that the insurer properly used the chiropractor acupuncture fee schedule and had paid the full amount due before suit, so the complaint was dismissed.
LVOV Acupuncture, P.C. v GEICO Ins. Co. (2011 NY Slip Op 51845(U)) Appellate Term, Second Department, October 11, 2011Excess shown for some charges, not for othersHeld, judicially noticing the schedule, that the insurer fully paid acupuncture codes 97810 and 97811 at the chiropractic rate, but that it offered no evidence defeating the $160.56 initial-visit charge under code 99204, which was awarded.
Points of Health Acupuncture, P.C. v GEICO Ins. Co. (2011 NY Slip Op 51843(U)) Appellate Term, Second Department, October 11, 2011Excess shown for some charges, not for othersHeld the insurer showed it fully paid some acupuncture claims at the judicially noticed chiropractic fee schedule rate, but failed to explain why it changed treatment codes for other dates of service, leaving those claims open.
Z.A. Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 51842(U)) Appellate Term, Second Department, October 11, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer showed it fully paid the acupuncture services under the judicially noticed chiropractic fee schedule and properly recoded former code 97780 to 97810, so those claims were dismissed.
LVOV Acupuncture, P.C. v GEICO (2011 NY Slip Op 51844(U)) Appellate Term, Second Department, October 11, 2011Excess shown for some charges, not for othersHeld the insurer fully paid codes 97810 and 97811 under the judicially noticed chiropractic schedule, searching the record to dismiss those claims, but offered nothing defeating the $160.56 initial-visit charge under code 99204.
LVOV Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 51721(U)) Appellate Term, Second Department, September 16, 2011Excess shown for some charges, not for othersHeld the insurer fully paid codes 97810 and 97811 under the judicially noticed chiropractic fee schedule, but upheld the provider's award for the 99204 initial visit because the insurer offered no evidence or argument against it.
W.H.O. Acupuncture, P.C. v Geico Indem. Co. (2011 NY Slip Op 51530(U)) Appellate Term, Second Department, August 4, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the chiropractor acupuncture fee schedule to pay a licensed acupuncturist, so its cross motion dismissing the complaint should have been granted.
W.H.O. Acupuncture, P.C. v Geico Gen. Ins. Co. (2011 NY Slip Op 51408(U)) Appellate Term, Second Department, July 25, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the chiropractor acupuncture fee schedule to pay the licensed acupuncturist, so its cross motion dismissing the complaint should have been granted.
Gentle Care Acupuncture, P.C. v GEICO (2011 NY Slip Op 51121(U)) Appellate Term, Second Department, June 14, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist's services at the chiropractor acupuncture rate and had fully paid what was due, so the complaint was dismissed.
Rogy Med., P.C. v Geico Ins. Co. (2011 NY Slip Op 50990(U)) Appellate Term, Second Department, May 26, 2011Insurer's proof did not establish the excess as a matter of law; question left for trialHeld an issue of fact existed as to whether the provider sought to recover more than the workers' compensation fee schedule permits, so the provider's summary judgment motion was denied on that claim.
Sung Bok Lee v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 50110(U)) Appellate Term, Second Department, January 26, 2011Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly reimbursed the licensed acupuncturist at the chiropractor acupuncture fee schedule rate, so summary judgment dismissing the complaint was correct.
Gentle Care Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 52226(U)) Appellate Term, Second Department, December 16, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld as a matter of law the insurer could pay a licensed acupuncturist at the chiropractor acupuncture rate, and since it undisputedly paid at that rate no further reimbursement was due.
Vincent Med. Servs., P.C. v GEICO Ins. Co. (2010 NY Slip Op 52153(U)) Appellate Term, Second Department, December 8, 2010Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer failed to raise a triable issue on its fee schedule defense because it did not specify the actual reimbursement rates underlying its reduction, so the provider was properly awarded summary judgment on those claims.
MIA Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 51899(U)) Appellate Term, Second Department, November 8, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the chiropractor acupuncture fee schedule to determine the amount payable to the licensed acupuncturist, so its reduced payments were proper.
Olga Bard Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 51898(U)) Appellate Term, Second Department, November 8, 2010Excess shown for some charges, not for othersHeld the insurer properly paid the licensed acupuncturist's codes 97810 and 97811 at the chiropractor acupuncture rate, but it offered insufficient evidence to defeat the claim for the initial visit, which was awarded to the provider.
Irina Kazanskaya, Ac v GEICO Ins. Co. (2010 NY Slip Op 51735(U)) Appellate Term, Second Department, October 1, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly reimbursed the acupuncturist at the chiropractor acupuncture rate and, as full payment at that rate was undisputed, searched the record and dismissed the complaint.
MIA Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51731(U)) Appellate Term, Second Department, October 1, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist at the chiropractor acupuncture rate and had fully paid the amount due under the fee schedule, so on searching the record the reduced claims were dismissed.
Point of Health Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51724(U)) Appellate Term, Second Department, October 1, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly used the chiropractor acupuncture fee schedule for a licensed acupuncturist's services and fully paid the amount due, so the unpaid portions were dismissed.
Neomy Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 51252(U)) Appellate Term, Second Department, July 16, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer made a prima facie showing that the unpaid portion of the bills exceeded the workers' compensation fee schedule and the provider failed to rebut it, so that claim was dismissed.
Raz Acupuncture, P.C. v AIG Indem. Ins. Co. (2010 NY Slip Op 51177(U)) Appellate Term, Second Department, July 7, 2010Excess shown for some charges, not for othersHeld payment of the acupuncture sessions at the medical-doctor rate, above the chiropractor rate, left nothing due, but the insurer's evidence did not warrant dismissing the claim for the initial acupuncture visit.
First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co. (2010 NY Slip Op 50594(U)) Appellate Term, Second Department, April 2, 2010Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer's timely denials asserting the services were part of another service and not separately reimbursable raised a triable issue, so neither party obtained summary judgment on those claims.
St. Vincent Med. Care, P.C. v Country Wide Ins. Co. (2010 NY Slip Op 50488(U)) Appellate Term, Second Department, March 19, 2010Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held the insurer failed even to raise an issue of fact on its fee schedule defense to the seventh cause of action because it annexed no proof that the fees exceeded the schedule, so the provider's award stood.
First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co. (2010 NY Slip Op 50149(U)) Appellate Term, Second Department, January 29, 2010Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer's unbundling fee schedule defense unproven because it submitted no affidavit from someone with sufficient expertise, so it raised no triable issue and the provider's summary judgment on those claims stood.
Canarsie Family Med. Practice, PLLC v American Tr. Ins. Co. (2010 NY Slip Op 50070(U)) Appellate Term, Second Department, January 12, 2010Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held that although the insurer was not precluded from asserting the defense, it failed to establish that the fees charged actually exceeded the workers' compensation fee schedule, so its motion was denied on that claim.
Amercure Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 50068(U)) Appellate Term, Second Department, January 12, 2010Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist at the chiropractor acupuncture rate and, as full payment at that rate was undisputed, searched the record and dismissed the complaint.
Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2010 NY Slip Op 50066(U)) Appellate Term, Second Department, January 12, 2010Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer raised an issue of fact as to whether the provider's fees were excessive, so the provider's summary judgment motion on that claim was denied and the matter remitted.
Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467) Leading case Appellate Term, Second Department, November 17, 2009Insurer proved the billed amount exceeded the applicable fee scheduleHeld as a matter of law, given licensure requirements, that an insurer may pay a licensed acupuncturist at the chiropractor acupuncture rate, and since it undisputedly did so nothing more was due.
New Wave Oriental Acupuncture, P.C. v Government Employees Ins. Co. (2009 NY Slip Op 52211(U)) Appellate Term, Second Department, October 23, 2009Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer properly used the chiropractor acupuncture rate, which raised a triable issue defeating the provider's motion, but declined to search the record and grant the insurer summary judgment.
Great Wall Acupuncture, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52308(U)) Appellate Term, Second Department, August 31, 2009Insurer proved the billed amount exceeded the applicable fee scheduleHeld it was proper for the insurer to pay the licensed acupuncturist at the chiropractor acupuncture rate, and since it timely paid at that rate, summary judgment dismissing the remaining claims was upheld.
Cornell Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 29228) Appellate Term, Second Department, May 22, 2009Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the insurer made a prima facie showing that charges for two paid claims exceeded the fee schedules, and the providers offered no evidence of interpretation or error, barring attorney's fees.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2009 NY Slip Op 51017(U)) Appellate Term, Second Department, May 19, 2009Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist's 21 sessions at the workers' compensation rate for acupuncture by chiropractors, so nothing more was due and the complaint was dismissed.
Rogy Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50732(U)) Leading case Appellate Term, Second Department, April 14, 2009Insurer's proof did not establish the excess as a matter of law; question left for trialHeld that although the insurer timely denied the claims on fee schedule grounds, it did not proffer sufficient evidence that the amounts charged exceeded the fee schedule, so its summary judgment motion was properly denied.
Alur Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51867(U)) Appellate Term, Second Department, September 10, 2008Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer showed a timely denial of the claim balance as excessive but did not establish as a matter of law that the fee charged was excessive.
R.J. Professional Acupuncturist, P.C. v NY Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 52729(U)) Appellate Term, Second Department, April 29, 2008Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Confirmed under rational-basis review a master arbitrator's award upholding denial of the licensed acupuncturist's claims, reasoning that when the award issued there was no settled appellate law on insurers' fee reductions for licensed acupuncturists.
AVA Acupuncture, P.C. v GEICO Gen. Ins. Co. (2007 NY Slip Op 27371) Appellate Term, Second Department, September 14, 2007Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the licensed acupuncturist at the chiropractor acupuncture rate rather than prevailing fees and, having undisputedly paid that amount in full, was granted summary judgment on searching the record.
Triboro Chiropractic & Acupuncture, PLLC v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51175(U)) Appellate Term, Second Department, June 8, 2007Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer did not proffer sufficient evidence to establish as a matter of law that the claims reflected incorrect amounts under the fee schedule.
Forrest Chen Acupuncture Servs., P.C. v GEICO Ins. Co. (2007 NY Slip Op 50874(U)) Appellate Term, Second Department, April 26, 2007Insurer proved the billed amount exceeded the applicable fee scheduleHeld that, with no fee schedule for licensed acupuncturists, the insurer could pay at the physical therapy rate as a similar procedure under 11 NYCRR 68.5 (b), and the provider did not dispute that similarity, so nothing more was due.
Great Wall Acupuncture v GEICO Gen. Ins. Co. (2007 NY Slip Op 27164) Appellate Term, Second Department, April 24, 2007Insurer proved the billed amount exceeded the applicable fee scheduleHeld a licensed acupuncturist's services were payable at the chiropractor acupuncture rate under 11 NYCRR 68.5 (b), and since the insurer had paid at that rate, nothing more was due.
A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2007 NY Slip Op 50680(U)) Appellate Term, Second Department, March 28, 2007Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer's assertion that it timely denied the remaining claims as exceeding the workers' compensation fee schedule raised a triable issue, defeating the provider's summary judgment motion on those claims.
Triboro Chiropractic & Acupuncture P.L.L.C v Allstate Ins. Co. (2006 NY Slip Op 51740(U)) Appellate Term, Second Department, September 14, 2006Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer's concurrent-care fee schedule defense raised no triable issue for lack of sufficient admissible evidence, and awarded the provider the claim.
Amaze Med. Supply Inc. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51051(U)) Appellate Term, Second Department, June 5, 2006Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer raised a triable issue of fact as to excessive billing, which together with the coverage issue required denial of the supplier's summary judgment motion.
Careplus Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 51526(U)) Appellate Term, Second Department, September 20, 2005Court finally rejected the fee schedule defense; provider recovers the disputed amountRejected as improper the insurer's partial denials based on suppliers' prevailing geographic rates, holding the 150%-of-cost limit was the only applicable fee schedule limitation, and granted the supplier summary judgment.
Careplus Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 51525(U)) Appellate Term, Second Department, September 20, 2005Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the partial denials based on suppliers' prevailing geographic rates improper because the 150-percent-of-cost rule was the only applicable limit for medical equipment, and awarded the supplier the claims.
Careplus Med. Supply, Inc v Allstate Indem. Co. (2005 NY Slip Op 51527(U)) Appellate Term, Second Department, September 20, 2005Court finally rejected the fee schedule defense; provider recovers the disputed amountRejected as improper the insurer's partial denials based on suppliers' prevailing geographic rates, holding the 150%-of-cost limit was the only applicable fee schedule limitation, and granted the supplier summary judgment.
S&M Supply Inc. v Progressive Ins. Co. (2005 NYSlipOp 51312(U)) Appellate Term, Second Department, August 17, 2005Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the timely partial denials based on charges exceeding the average wholesale cost stated no valid basis under the pre-October 2004 DME rule, which capped recovery at 150% of cost, and awarded the supplier the full amount.
Triboro Chiropractic & Acupuncture P.L.L.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50856(U)) Appellate Term, Second Department, June 1, 2005Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the timely fee schedule and rating denials raised triable issues of fact, so the provider's motion was denied as to those claims.
King'S Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 50280(U)) Appellate Term, Second Department, April 9, 2004Insurer's proof did not establish the excess as a matter of law; question left for trialHeld triable issues existed on the timely denied supply claims under the 150%-of-cost rule, including whether the provider actually paid the invoice prices, so summary judgment was denied on those claims.
Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 24119) Appellate Term, Second Department, April 9, 2004Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer could not reduce medical equipment charges to prevailing geographic rates because the 150-percent-of-cost limit was the applicable fee schedule, so that defense lacked merit and the supplier recovered.
Abraham v Country-Wide Ins. Co. (2004 NY Slip Op 50388(U)) Appellate Term, Second Department, February 10, 2004Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held the insurer, though entitled to raise the defense by timely denial, offered no evidentiary proof that any charge exceeded the fee schedule, insufficient even to raise a triable issue.
King'S Med. Supply v Allstate Ins. Co. (2003 NY Slip Op 51681(U)) Appellate Term, Second Department, December 22, 2003Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer could not reduce medical equipment charges to the geographic prevailing rate because the 150%-of-cost rule is the applicable fee schedule, so the provider was granted summary judgment.
King'S Med. Supply v Allstate Ins. Co. (2003 NY Slip Op 51680(U)) Appellate Term, Second Department, December 22, 2003Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer's objection that the supplier's equipment prices exceeded prevailing geographic rates was not a proper defense, for the reasons in the companion case, and granted the supplier summary judgment.

Trial courts in the First Department (12 decisions)

Balance Art Acupuncture P.C. v MVAIC (2022 NY Slip Op 22061) Civil Court of the City of New York, New York County, February 9, 2022Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's trained claims representative's affidavit applying the chiropractor conversion factor and relative values established full payment, and the acupuncturist raised no triable issue because it showed no history of physician-rate reimbursement.
Harvey Family Chiro PT & Acup, PLLC v Ameriprise Ins. Co. (2020 NY Slip Op 20136) Civil Court of the City of New York, Bronx County, June 15, 2020Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to make a prima facie fee schedule showing because it offered no affidavit from anyone familiar with coding, and counsel's affirmation lacked personal knowledge.
NYC Sports Acupuncture PC v MVAIC (2020 NY Slip Op 50393(U)) Civil Court, New York County, April 7, 2020Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish as a matter of law that the acupuncture charges exceeded the fee schedule, since the chiropractor schedule does not foreclose the physician schedule in all cases.
Ancient & Modern Acupuncture, P.C. v MVAIC (2020 NY Slip Op 50011(U)) Civil Court of the City of New York, New York County, January 7, 2020Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the chiropractic fee schedule's eight-unit ground rule could not be applied to cupping by a licensed acupuncturist, and awarded the provider the reduced difference.
Acupuncture Approach, P.C. v USAA Gen. Indem. Co. (2018 NY Slip Op 50807(U)) Civil Court of the City of New York, New York County, April 24, 2018Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held a claims adjuster's affidavit with fee schedule excerpts could explain the calculation without an expert, and rejected the provider's Ingenix challenge, though the motion failed on mailing.
Maidstone Ins. Co. v Medical Records Retrieval, Inc. (2018 NY Slip Op 50556(U)) Supreme Court, Bronx County, April 4, 2018Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Confirmed an award rejecting the insurer's DME rental fee defense, holding it rational that unlisted items with no Health Department rental price are paid at the rate charged to the general public.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U)) Civil Court of the City of New York, Bronx County, March 15, 2018Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer fully paid under the chiropractic fee schedule because an unrebutted certified coder's affidavit showed the nerve testing should be valued under code 95904 per extremity, and counsel's affirmation could not raise a triable issue.
Allstate Ins. Co. v Health E. Ambulatory Surgical Ctr. (2017 NY Slip Op 50574(U)) Supreme Court, New York County, March 20, 2017Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld under the New Jersey schedule that the add-on and modifier codes were exempt from the 50% multiple-procedure reduction, so the insurer's reductions were wrong and the provider recovered the full scheduled amount.

Show all 12 decisions

Saddle Brook Surgicenter, LLC v All State Ins. Co. (2015 NY Slip Op 25099) Civil Court of the City of New York, Bronx County, April 7, 2015Insurer proved the billed amount exceeded the applicable fee scheduleHeld the prevailing fee under 11 NYCRR 68.6 for New Jersey services is the New Jersey fee schedule amount, and the certified coder's affidavit showed the insurer's partial payment matched it, warranting dismissal.
Avanguard Med. Group, PLLC(b) v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51940(U)) Civil Court of the City of New York, New York County, December 12, 2014Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held an office-based surgery facility not licensed under Article 28 could not bill a facility fee under the PAS schedule, so the insurer properly denied the claim.
Surgicare Surgical v National Interstate Ins. Co. (2014 NY Slip Op 24362) Civil Court of the City of New York, Bronx County, November 17, 2014Insurer proved the billed amount exceeded the applicable fee scheduleHeld that for out-of-state services the insurer complies with 11 NYCRR 68.6 by paying the host state's fee schedule amount, and undisputed payment under New Jersey's schedule left nothing more due.
Acupuncture Approach P.C. v MVAIC (2013 NY Slip Op 50720(U)) Civil Court, New York County, January 28, 2013Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer properly paid the acupuncturist under the schedule for doctors and chiropractors performing acupuncture, rejecting the unpublished-schedule challenge because publication was waived for fees under $100, and dismissed the complaint.

Trial courts in the Second Department (39 decisions)

NR Motion PT, P.C. v Allstate Ins. (2026 NY Slip Op 51460(U)) Civil Court of the City of New York, Kings County, September 3, 2026Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to establish its fee schedule defense as a matter of law because it submitted no competent admissible evidence that the charges exceeded the applicable schedule, leaving the defense for trial.
Acupuncture Care, PC. v State Farm Mut. Auto. Ins. Co. (2026 NY Slip Op 50991(U)) Civil Court of the City of New York, Richmond County, June 11, 2026Excess shown for some charges, not for othersAccepted the insurer's coder affirmation as unrebutted, dismissing the claims beyond the schedule amounts but awarding the small balance the coder found still owed for three billing periods.
334 Grand Concourse Med., P.C. v Plymouth Rock Assur. (2026 NY Slip Op 50539(U)) Civil Court of the City of New York, Kings County, April 15, 2026Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the provider owner's rebuttal affidavit, disputing the insurer's certified coder, raised a triable issue on the fee schedule calculation; a rebutting affiant need not be a certified coder.
Atlantic Med. & Diagnostic, P.C. v State Farm Mut. Auto. Ins. Co. (2024 NY Slip Op 51785(U)) District Court of Suffolk County, Third District, December 12, 2024Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld after trial that the fee schedule itself, including Radiology Ground Rule 3, permits billing multiple units of ultrasound guidance with trigger point injections, rejecting the insurer's coder's reliance on AMA guidance.
Advanced Recovery Equip. & Supplies v Travelers Ins. Co. (2022 NY Slip Op 50690(U)) Civil Court of the City of New York, Queens County, July 21, 2022Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish the fee schedule defense because its medical appeals analyst did not state qualifications showing she was an expert able to interpret the fee schedule.
SB Chiropractic, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50316(U)) Civil Court of the City of New York, Kings County, April 20, 2022Insurer proved the billed amount exceeded the applicable fee scheduleHeld the insurer's affidavit and affirmation properly applied fee schedule ground-rule RVU caps and prior payments to another provider, and the provider's rebuttal affidavit addressed codes not billed, so the reductions were proper.
Demas v State Farm Fire & Cas. Co. (2022 NY Slip Op 50250(U)) Civil Court of the City of New York, Kings County, April 6, 2022Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the coder's downcoding of cupping and borrowed relative value rested on an unauthoritative source and unreliable hearsay, so the insurer failed to establish proper fee schedule payment as a matter of law.
Optimum Health Acupuncture, P.C. v Integon Natl. Ins. Co. (2022 NY Slip Op 50068(U)) District Court of Suffolk County, Fourth District, January 5, 2022Insurer proved the billed amount exceeded the applicable fee scheduleHeld the certified coder's affidavit established the billing exceeded the fee schedule, and the provider's missing coder affidavit left only an attorney's opposition without personal knowledge, raising no triable issue.

Show all 39 decisions

New York Med. & Diagnostic Ctr. v GEICO Ins. Co. (2021 NY Slip Op 51138(U)) Civil Court of the City of New York, Queens County, December 2, 2021Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed its initial burden on the reduced bill because its claims associate was not a fee schedule expert and the explanation of review alone did not show the billing exceeded the schedule.
Tandingan PT PC v State Farm Fire & Cas. Co. (2021 NY Slip Op 50869(U)) Civil Court of the City of New York, Queens County, September 16, 2021Insurer proved the billed amount exceeded the applicable fee scheduleHeld that a certified coder's affidavit, showing the provider used an incorrect code, and proof of timely partial payment established that the insurer paid the claim in full under the fee schedule, so the balance was dismissed.
Medalliance Med. Health Servs. v Travelers Prop. Cas. Ins. Co. (2021 NY Slip Op 50737(U)) District Court of Suffolk County, Fourth District, June 30, 2021Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish its fee schedule defense because it offered no coder or claim representative affidavit explaining the relative values and conversion factors applied, and its PPO-rate reductions were not shown applicable.
Barakat P.T., P.C. v Progressive Ins. Co. (2021 NY Slip Op 50342(U)) Civil Court of the City of New York, Kings County, April 9, 2021Insurer's proof did not establish the excess as a matter of law; question left for trial (also decides)Held the insurer failed to show the charges exceeded the fee schedule because only counsel, not a coder or examiner, asserted the physical therapist conversion factor applied, without ground rules or authority.
All Healthy Style Med., P.C. v ELRAC, Inc. (2018 NY Slip Op 51333(U)) Civil Court of the City of New York, Kings County, May 16, 2018Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish that the charges exceeded the fee schedule because its adjuster's affidavit was conclusory, internally inconsistent, showed no fee schedule training, and did not explain the codes or calculation behind the reductions.
Advanced Recovery Equip. & Supplies, LLC v Maya Assur. Co. (2018 NY Slip Op 50022(U)) Civil Court of the City of New York, Queens County, January 3, 2018Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to prove the DME rental charges exceeded the fee schedule because no Medicaid MRA or Health Department area-office rate existed, leaving only the general public rental charge as the limit.
Accelerated Chiropractic Care P.C. v Progressive Ins. (2017 NY Slip Op 51967(U)) Civil Court of the City of New York, Kings County, December 13, 2017Insurer proved the billed amount exceeded the applicable fee scheduleAfter trial, credited the insurer's uncontroverted testimony on proper codes, modifiers and the multiple procedure rule, finding the correct fee schedule amount was $1,462.47 rather than $3,572.91, and limited judgment accordingly.
Professional Chiropractic Care, P.C. v 21st Century Ins. Co. (2017 NY Slip Op 27380) District Court of Suffolk County, Third District, November 27, 2017Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the insurer's certified coder's affidavit, unrebutted by the provider, established that the New Jersey fee schedule allowed only $9,160.08, and reduced the amount in dispute accordingly.
Tyorkin v Garrison Prop. & Cas. Ins. Co. (2016 NY Slip Op 50846(U)) Civil Court of the City of New York, Kings County, May 20, 2016Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the New Jersey schedule governed and the defense was not precludable, but the coder's unexplained calculation only raised a triable issue and could not support summary judgment, so the fee schedule defense went to trial.
East Coast Acupuncture, P.C. v Hereford Ins. Co. (2016 NY Slip Op 26042) Civil Court of the City of New York, Kings County, February 9, 2016Insurer proved the billed amount exceeded the applicable fee scheduleHeld, on the unopposed affidavit of a certified coder explaining the calculation and copies of checks, that the insurer had paid the acupuncturist at the chiropractor rate in accordance with the fee schedule, so nothing more was owed.
Village Chiropractic v Geico Ins. Co. (2015 NY Slip Op 51189(U)) District Court of Nassau County, First District, August 17, 2015Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the claims examiner's affidavit that five claims were reduced under the applicable fee schedule did not establish the charges exceeded the schedule, leaving issues of fact for trial.
Doctor of Medicine in the House, P.C. v Allstate Ins. Co. (2013 NY Slip Op 23357) District Court of Suffolk County, Third District, September 30, 2013Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld after a framed-issue trial that Ground Rule 11's eight-unit daily cap applies per provider, not cumulatively across providers like the section 65-3.15 exhaustion rule, so the insurer's denial failed and the provider recovered eight of its ten units.
Allstate Ins. Co. v Natural Healing Acupuncture, P.C. (2013 NY Slip Op 50645(U)) Civil Court of the City of New York, Kings County, April 3, 2013Insurer's proof did not establish the excess as a matter of law; question left for trialVacated the master arbitrator's award applying the physician acupuncture rate as contrary to settled law and directed recalculation of the licensed acupuncturist's fees under the chiropractor acupuncture schedule.
Upper E. Side Surgical, PLLC v State Farm Ins. Co. (2012 NY Slip Op 50184(U)) District Court of Nassau County, First District, February 2, 2012Insurer's proof did not establish the excess as a matter of law; question left for trialHeld an accredited office-based surgery facility could not use the ambulatory surgery facility fee schedule but no adopted schedule applied, so its fee was the prevailing local fee and a triable issue on the amount remained.
All Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 50137(U)) Civil Court of the City of New York, Kings County, January 31, 2012Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held at trial that the fee schedule defense failed because the insurer offered no testimonial or documentary evidence that the charges exceeded the fee schedule, and the provider recovered the services not defeated on necessity.
Novacare Med. P.C. v Travelers Prop. Cas. Ins. Co. (2011 NY Slip Op 50500(U)) District Court of Nassau County, Second District, April 1, 2011Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the insurer established its fee schedule reduction through proper proof as a matter of law, the provider raising no triable issue, so no further proof of the reduction was needed at trial.
John Giugliano, DC, P.C. v Merchants Mut. Ins. Co. (2010 NY Slip Op 20308) Civil Court of the City of New York, Kings County, July 27, 2010Court finally rejected the fee schedule defense; provider recovers the disputed amountAfter trial limited to fee schedule application, held the chiropractor properly billed unlisted procedures under surgery CPT codes as co-surgeon, rebutting the insurer's analyst, and awarded the full amount.
Custis v Travelers Prop. Cas. Ins. Co. (2010 NY Slip Op 20118) District Court of Suffolk County, Third District, April 7, 2010Excess shown for some charges, not for othersHeld the insurer showed its Ground Rule 11 reductions, the disallowed new-patient visit codes and the 99213 recalculation were correct, but its coder's conclusory recoding of 99244 and 99214 claims did not establish proper payment.
Jesa Med. Supply, Inc. v GEICO Ins. Co. (2009 NY Slip Op 29386) Civil Court of the City of New York, Kings County, September 22, 2009Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld the insurer's affidavit did not explain how the fee schedule was applied or how the charge exceeded it, so the provider was granted summary judgment for the reduced balance.
Midwood Acupuncture, P.C. v Allstate Ins. Co. (2009 NY Slip Op 50459(U)) Civil Court of the City of New York, Kings County, March 6, 2009Insurer proved the billed amount exceeded the applicable fee scheduleAfter trial, held the insurer met its burden by showing it paid the licensed acupuncturist at the chiropractor fee schedule rate, and the provider did not rebut the defense.
Lenox Hill Radiology v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 28275) District Court of Nassau County, First District, July 25, 2008Insurer's proof did not establish the excess as a matter of law; question left for trialHeld the insurer failed to establish that MRI charges exceeded the fee schedule because it relied only on counsel's affirmation, a conclusory examiner statement and a non-binding federal decision applying the X-ray multiple-procedure rule.
St. Vincent's Hosp. of Richmond v State Farm Mut. Auto. Ins. Co. (2007 NY Slip Op 52534(U)) Supreme Court, Nassau County, December 31, 2007Insurer's proof did not establish the excess as a matter of law; question left for trialHeld a question of fact existed whether the hospital's charges exceeded the workers' compensation fee schedule despite the timely partial denial, so both motions were denied and a hearing ordered on the amount due.
Complete Orthopedic Supplies, Inc. v State Farm Ins. Co. (2007 NY Slip Op 27192) Civil Court of the City of New York, Queens County, May 14, 2007Insurer's proof did not establish the excess as a matter of law; question left for trialHeld that the insurer did not establish a proper scheduled fee or a comparable fee for the medical goods, so triable issues of fact remained as to the proper scheduled fees.
Robert Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 26240) Civil Court, Kings County, June 21, 2006Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld a physical therapist could bill range-of-motion and muscle-testing codes from the medicine section, and the insurer offered no competent proof that those tests were bundled into evaluation services, so the provider recovered the disputed amounts.
Roberts Physical Therapy, P.C. v State Farm Mut. Auto Ins. Co. (2006 NY Slip Op 52565(U)) Civil Court of the City of New York, Kings County, May 30, 2006Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld after trial that the range-of-motion and muscle-testing codes were listed in the schedule and billed at the proper physical therapist rate, and the insurer offered no contrary proof.
Power Acupuncture P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 50393(U)) Civil Court of the City of New York, Kings County, March 20, 2006Court finally rejected the fee schedule defense; provider recovers the disputed amountHeld a licensed acupuncturist is paid the prevailing fee under 11 NYCRR 68.5(b), so the insurer's reduction to the physician acupuncture rate was wrong and unsupported by evidence of similar procedures; provider awarded the balance.
Macintosh Med., P.C. v State Farm Mut. Auto Insur. Co. (2005 NY Slip Op 51440(U)) District Court of Nassau County, Third District, September 13, 2005Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held the provider lacked a meritorious claim because the workers' compensation fee schedule reimburses physical medicine only when performed by physicians or licensed therapists, not licensed massage therapists.
Great Wall Acupuncture, P.C. v GEICO Gen. Ins. Co. (2005 NY Slip Op 51199(U)) Civil Court of the City of New York, Kings County, July 28, 2005Insurer's proof did not establish the excess as a matter of law; question left for trialHeld whether a licensed acupuncturist's treatment is similar to chiropractic acupuncture, so as to justify the insurer's reduction to the chiropractor rate, was a triable fact issue, and counsel's affirmation could not show a higher prevailing fee.
A.B. Med. Servs. P.L.L.C. v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50662(U)) Civil Court of the City of New York, Kings County, April 29, 2005Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held on uncontroverted expert testimony that motor nerve testing was redundantly billed under two code categories, reducing the bill by $425.88.
A.B. Med. Servs. PLLC v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 51847(U)) Civil Court of the City of New York, Kings County, November 10, 2004Court finally rejected the fee schedule defense; provider recovers the disputed amount (also decides)Held the insurer submitted no evidentiary proof that the charges for medical supplies exceeded the 150%-of-cost fee schedule limit, and awarded the providers the full amount, the defense also being precluded by the untimely denial.
Careplus Med. Supply Inc. v Allstate Indem. Co. (2004 NY Slip Op 51148(U)) Civil Court, Kings County, September 24, 2004Court finally rejected the fee schedule defense; provider recovers the disputed amountRejected the insurer's reduction of the equipment charges, holding the invoices and cancelled checks sufficiently documented the cost under the 150%-of-cost limit, so the disputed amounts were awarded.

Trial courts in the Fourth Department (1 decision)

Proscan Radiology of Buffalo v Progressive Cas. Ins. Co. (2006 NY Slip Op 51242(U)) City Court of Buffalo, June 27, 2006Insurer proved the billed amount exceeded the applicable fee schedule (also decides)Held, by judicial notice of the applicable workers' compensation schedule, that the MRI charges exceeded the scheduled fees, which barred attorney's fees though the untimely denial precluded the fee schedule defense to payment.

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