October 13, 2016

Renelique v American Tr. Ins. Co. (2016 NY Slip Op 51526(U))

https://www.beynensonlaw.com/case-law/renelique-v-american-tr-ins-co-2016-ny-slip-op-51526u/

Court: Appellate Term, Second Department
Decided: October 13, 2016
Citation: 2016 NY Slip Op 51526(U) · 53 Misc 3d 141(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 3 later decisions (see Cited by)
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

Renelique v American Tr. Ins. Co., 53 Misc 3d 141(A), 2016 NY Slip Op 51526(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016)

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 established fee-schedule reimbursement using assigned relative values, and the provider failed to rebut its calculation. The provider billed CPT codes 99244 and 20553. The insurer's no-fault examiner explained the calculation using the applicable relative value and conversion factor. The provider's doctor's unsupported assertion that code 20553 was a "by report" code without a relative value did not rebut the insurer's proof. Additional objections to the coding expert's affidavit and a specific argument concerning code 99244 were unpreserved. The Appellate Term, Second Department, affirmed the denial of the provider's summary judgment motion and the grant of the insurer's cross motion dismissing the complaint.

Reported in New York Official Reports at Renelique v American Tr. Ins. Co. (2016 NY Slip Op 51526(U))

[*1]

Renelique v American Tr. Ins. Co.

2016 NY Slip Op 51526(U) [53 Misc 3d 141(A)]

Decided on October 13, 2016

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on October 13, 2016

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2014-264 Q C

Pierre Jean Jacques Renelique, as Assignee of BRANDON CARTIE, Appellant,
against
American Transit Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Ulysses Bernard Leverett, J.), entered December 11, 2013. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Plaintiff billed for one unit of CPT code 99244 at $236.94 and one unit of CPT code 20553 at $600. Defendant defended this action on the ground that the fees sought exceeded the amounts permitted for those codes by the workers’ compenCsation fee schedule. While plaintiff argues on appeal that the affidavit executed by defendant’s coding expert “does not discuss anything specific whatsoever regarding [p]laintiff’s claims,” defendant also submitted an affidavit executed by its no-fault examiner, who described how the fees for the services at issue had been calculated by multiplying the appropriate “relative value” by the appropriate “conversion factor.” Plaintiff’s remaining argument with respect to the coding expert’s affidavit and the specific argument made by plaintiff with regard to CPT code 99244 were not raised in the Civil Court, and are therefore not properly before this court.

With respect to plaintiff’s final argument, which involves CPT code 20553, we find that defendant made a prima facie showing that it had used the assigned relative value for that code to calculate the sum to which plaintiff was entitled to be reimbursed. While plaintiff submitted a doctor’s affidavit addressing CPT code 20553, the doctor’s conclusion is based upon the unsupported allegation that CPT code 20553 is a “by report” code, meaning that it does not have a relative value. This allegation does not rebut defendant’s proof that CPT code 20553 does have a relative value.

Accordingly, the order is affirmed.

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

Decision Date: October 13, 2016

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.

Proving a fee schedule defense

Open the full map

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

This decision: Insurer proved the billed amount exceeded the applicable fee schedule

Held 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.

Excess shownNot established; openDefense rejectedSplit by chargeThis decisionCites it or cited by itCited or followed

Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 147 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited by

A label shows how the later decision treated this one.

Demas v State Farm Fire & Cas. Co. (2022 NY Slip Op 50250(U)) FollowedThe insurer failed to justify recoding cupping or applying a vasopneumatic-device valuation under the fee schedule.
Balance Art Acupuncture P.C. v MVAIC (2022 NY Slip Op 22061) FollowedMVAIC established proper payment at chiropractic acupuncture rates, and the provider failed to show that physician rates should apply.
SB Chiropractic, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50316(U)) FollowedThe insurer established timely denials, proper fee-schedule reductions and lack of medical necessity for post-IME treatment.
Barakat P.T., P.C. v Progressive Ins. Co. (2021 NY Slip Op 50342(U))The insurer established a timely deductible denial even though it failed to substantiate its fee-schedule reduction.

Similar decisions

Renelique v Allstate Ins. Co. (2017 NY Slip Op 51141(U))The insurer established proper application of the workers' compensation fee schedule to CPT code 20553, and the provider did not rebut its showing.
Renelique v Tri State Consumers Ins. Co. (2016 NY Slip Op 50866(U))The provider's challenge to the specificity of the insurer's fee schedule denial failed, and its calculation argument was unpreserved.
Renelique v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50868(U))The insurer's affidavit established timely and proper mailing of the denial based on the assignor's IME nonappearance.
Renelique Med. Servs., P.C. v Travelers Ins. Co. (2018 NY Slip Op 50817(U))The insurer's proof established the provider's EUO nonappearances, and the provider's remaining argument was raised for the first time on appeal.
Renelique v National Liab. & Fire Ins. Co. (2016 NY Slip Op 51613(U))The insurer failed to prove mailing of the IME scheduling letters and therefore failed to establish that the assignor's IMEs were properly scheduled.