January 20, 2017

Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2017 NY Slip Op 50101(U))

https://www.beynensonlaw.com/case-law/bronx-acupuncture-therapy-p-c-v-hereford-ins-co-2017-ny-slip-op50101u/

Court: Appellate Term, Second Department
Decided: January 20, 2017
Citation: 2017 NY Slip Op 50101(U)
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 3 later decisions (see Cited by)
Issues: Fee schedule Verification requests

Cite as

Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co., 2017 NY Slip Op 50101(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017)

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.

The insurer failed to establish a fee-schedule defense for codes 97039 and 99199 because it did not request needed verification. The provider billed moxibustion and acupressure under codes designated "By Report," which have no assigned relative value and require supporting documentation to determine reimbursement. Although the provider omitted that documentation, the insurer did not request additional verification within 15 business days under 11 NYCRR 65-3.5 (b) and did not demonstrate that it requested the needed information. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and denied summary judgment dismissing the claims under those two codes.

Reported in New York Official Reports at Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2017 NY Slip Op 50101(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

Bronx Acupuncture Therapy, P.C., as Assignee of NIURKA MEJIA, Appellant,
against
Hereford Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Reginald A. Boddie, J.), entered January 23, 2015. The 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 codes 97039 and 99199 of the workers’ compensation fee schedules.

ORDERED that the order, insofar as appealed from, is reversed, with $30 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 codes 97039 and 99199 of the workers’ compensation fee schedules 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 fully paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedules. The Civil Court granted defendant’s motion in its entirety. As limited by its brief, plaintiff appeals from so much of the Civil Court’s order as granted the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under codes 97039 and 99199 of the workers’ compensation fee schedules.

The record reflects that plaintiff submitted three claim forms to defendant which included charges for 21 sessions of moxibustion, under code 97039, which is described as “Unlisted modality (specify type and time if there was constant attendance)” and for one session of acupressure, under code 99199, which is described as “Unlisted special service, procedure or report.” The workers’ compensation fee schedules do not assign a relative value to either of those codes, but instead have assigned them a “By Report” designation, which requires a provider to furnish certain additional documentation to enable the insurer to determine the appropriate amount of reimbursement. Plaintiff did not provide such documentation with its claim forms and defendant did not, within 15 business days of its receipt of the claim forms, request “any additional verification required by the insurer to establish proof of claim” (11 NYCRR 65-3.5 [b]). As defendant failed to demonstrate upon its motion that it had requested any additional verification from plaintiff seeking the information it required in order to review plaintiff’s claims for services billed under codes 97039 and 99199 of the workers’ compensation fee schedules, defendant was not entitled to summary judgment dismissing so much of the complaint as sought [*2]to recover for services rendered under those codes (see Gaba Med., P.C. v Progressive Specialty Ins. Co., 36 Misc 3d 139[A], 2012 NY Slip Op 51448[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]; see generally Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]).

Accordingly, the 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 codes 97039 and 99199 of the workers’ compensation fee schedules are denied.

Elliot, J.P., Pesce and Solomon, JJ., concur.

Decision Date: January 20, 2017

Cited in this decision

A label shows how this decision treated the case it cites.

Gaba Med., P.C. v Progressive Specialty Ins. Co. (2012 NY Slip Op 51448(U)) FollowedThe insurer's reduction of a time-based claim to one unit lacked a factual basis because it never sought verification of the time spent.
Rogy Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50732(U))The insurer's peer review report was not competent evidence, and its fee-schedule proof was insufficient.

Cited by

A label shows how the later decision treated this one.

Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2017 NY Slip Op 51452(U)) FollowedAn insurer must request missing documentation for a By Report claim before denying it for lack of that documentation.
Pavlova v Allstate Ins. Co. (2018 NY Slip Op 51604(U)) FollowedAn insurer must request supporting documentation before denying a By Report claim for insufficient documentation.
Pavlova v Allstate Ins. Co. (2018 NY Slip Op 51654(U)) FollowedAn insurer must request missing documentation for a "By Report" claim before denying payment for insufficient documentation.
Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2019 NY Slip Op 06059)An insurer that fails to request verification cannot deny a moxibustion claim under CPT code 97039 for insufficient information.

Similar decisions

Acuhealth Acupuncture, P.C. v Hereford Ins. Co. (2017 NY Slip Op 51871(U))The insurer failed to show that it requested verification of the documentation needed to price services billed under CPT code 97039.
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.
2 & 9 Acupuncture, P.C. v 21st Century Advantage Ins. Co. (2017 NY Slip Op 50599(U))The insurer's summary judgment motion was denied on appeal as to unpaid services billed under CPT codes 97026 and 97016.
Oleg’s Acupuncture, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50095(U))An insurer need not issue a timely denial to preserve a fee-schedule defense for services rendered on or after April 1, 2013.
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.