April 27, 2017
2 & 9 Acupuncture, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50599(U))
https://www.beynensonlaw.com/case-law/2-9-acupuncture-p-c-v-21st-century-advantage-ins-co-2017-ny-slip-op50599u/
- Decided
- April 27, 2017
- Citation
- 2017 NY Slip Op 50599(U)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Issues
- Fee schedule
- Legal questions
- Proving a fee schedule defense (see the maps)
Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.
Summary
Editorial summary by Beynenson Law, not part of the court’s decision.
Reported in New York Official Reports at 2 & 9 Acupuncture, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50599(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS
against
21st Century Advantage Insurance Company, Respondent.
Gabriel & Shapiro, LLC (Steven F. Palumbo, Esq.), for appellant. Law Office of Bryan M. Rothenberg (Kenneth F. Popper, Esq.), for respondent.
Appeal from an amended order of the District Court of Suffolk County, Third District (C. Stephen Hackeling, J.), dated January 20, 2016. The amended order, insofar as appealed from as limited by the brief, granted the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97026 and 97016.
ORDERED that, on the court’s own motion, the notice of appeal from an order dated December 23, 2015 is deemed a premature notice of appeal from the amended order dated January 20, 2016 (see CPLR 5520 [c]); and it is further,
ORDERED that the amended order, insofar as appealed from, is reversed, without costs, and the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97026 and 97016 are denied.
In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint, arguing that it had paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedule. In an amended order dated January 20, 2016, the District Court granted defendant’s motion in its entirety. On appeal, plaintiff argues that the District Court should have denied the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97026 and 97016.
Upon a review of the record, we find that defendant failed to demonstrate, prima facie, that it had properly denied payment for the unpaid portions of the bills for services billed under [*2]CPT codes 97026 and 97016 in accordance with the workers’ compensation fee schedule (see Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129[A], 2016 NY Slip Op 51359[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co., 36 Misc 3d 133[A], 2012 NY Slip Op 51335[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]).
Accordingly, the amended order, insofar as appealed from, is reversed and the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97026 and 97016 are denied.
Marano, P.J., Garguilo and Brands, JJ., concur.
Decision Date: April 27, 2017
Legal questions
A question of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.
Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?
This decision: Insurer's proof did not establish the excess as a matter of law; question left for trial
Held 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.
Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 85 (this one included) are in the same category.
Cited in this decision
- Sama Physical Therapy, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51359(U))The insurer established proper recoding of physical therapy services but failed to justify Ground Rule 11 reductions on three claims.
- W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co. (2012 NY Slip Op 51335(U))The insurer failed to explain why it reduced some CPT code 97811 claims but denied others entirely for missing time documentation.
Similar decisions
- New Age Acupuncture, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 50737(U))The insurer's summary judgment motion concerning services billed under CPT code 97026 was denied on appeal.
- Acupuncture Healthcare Plaza I, P.C. v 21st Century Ins. Co. (2015 NY Slip Op 51716(U))The insurer proved its acupuncture fee-schedule reductions, but a factual issue over the IME notice address defeated dismissal of two claims.
- Charles Deng Acupuncture, P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51252(U))An insurer may use the chiropractors' acupuncture fee schedule to determine reimbursement for a licensed acupuncturist's services.
- Gl Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51419(U))The insurer proved fee-schedule payment for services billed under CPT codes 97810 and 97811, but not entitlement to dismiss the initial-visit claim.
- Acupuncture Approach, P.C. v NY Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51455(U))The insurer failed to establish timely denials preserving its fee-schedule defense to three claims.