Trial court, Second Department
Dec 12, 2024
2024 NY Slip Op 51785(U)
Provider prevailed
Multiple units of CPT code 76942 are reimbursable under the Workers' Compensation Medical Fee Schedule with trigger point injections. After a joint trial of two no-fault actions, the District Court, Suffolk County, awarded judgment to the providers. The insurer had paid for one unit of ultrasound guidance accompanying injections billed under CPT code 20553 and denied the remaining units. The court treated the fee schedule as the primary authority and read its general ground rules and Radiology Ground Rule Three as permitting multiple reimbursements. AMA coding materials supporting a single unit did not supersede the fee schedule's express rules. The testimony and evidence established that the multiple units were properly billed.
Trial court, Second Department
Jan 17, 2024
2024 NY Slip Op 50126(U)
Provider prevailed
The provider's arbitration award was confirmed because the record supplied a rational basis and supported the master arbitrator's affirmance. The District Court, Suffolk County, granted the provider's unopposed petition under CPLR 7510, filed within one year after delivery of the master arbitration award. The award had not been vacated or modified on a ground specified in CPLR 7511. The master arbitrator found the initial award clearly articulated and supported by the evidence, with no valid ground to set it aside. The court agreed and confirmed the award, including interest under Insurance Law § 5106 (a), and granted additional attorney fees for the judicial proceeding under 11 NYCRR 65-4.10 (j) (4).
Trial court, Second Department
Jan 5, 2022
2022 NY Slip Op 50068(U)
Insurer prevailed
The provider failed to raise factual issues on fee-schedule reductions and medical necessity because its expert affidavits were missing. The District Court, Suffolk County, granted the insurer's summary judgment motion under CPLR 3212 (b) and dismissed the complaint. The insurer submitted a certified professional coder's affidavit supporting fee-schedule reductions, along with IME and peer review reports supporting lack of medical necessity. Although the provider's opposition purported to attach rebuttal affidavits from its coding and medical experts, none were submitted. Counsel's analysis, without personal knowledge or supporting expert evidence, could not defeat the motion. The insurer's calculations and medical opinions therefore remained unrebutted.
Trial court, Second Department
Sep 23, 2021
2021 NY Slip Op 50945(U)
The insurer's IME no-show defense failed because the examinations were not timely scheduled under 11 NYCRR 65-3.5 (d). The District Court, Suffolk County, denied both the insurer's summary judgment motion and the provider's cross motion. Although mailing and nonappearance were established, the insurer failed to show that the IMEs complied with the 30-day requirement or that verification requests tolled that period. The provider's reliance on denial forms was insufficient without claim forms and a billing manager's affidavit establishing personal knowledge of their issuance. Prior judgments involving other providers and the same assignor did not establish res judicata without proof of privity and the same transaction. The court expressly made no ruling on other IMEs, fee schedule objections, or allegedly inaccurate insurance information.
Trial court, Second Department
Jun 30, 2021
2021 NY Slip Op 50737(U)
Split result
The insurer's misaddressed verification requests failed to toll the 30-day period to pay or deny the provider's claims. The District Court, Suffolk County, denied dismissal and awarded the provider summary judgment on those claims and ten claims supported by postal mailing proofs. Those claims were overdue under Insurance Law § 5106 (a) and 11 NYCRR 65-3.8 (a) (1), warranting judgment under CPLR 3212 (b). Conflicting medical opinions required trial. The late-submission claim remained for trial under alternative repudiation and justification analyses, applying 11 NYCRR 65-3.5 (l). The insurer obtained partial dismissal for prior payments proved by deposited checks, but failed to substantiate fee-schedule calculations or PPO applicability for the unpaid balances.
Trial court, Second Department
Jan 20, 2020
2020 NY Slip Op 50106(U)
Split result
The insurer failed to show that the out-of-state provider was doing business in New York under Business Corporation Law § 1312 (a). The District Court, Suffolk County, denied with prejudice dismissal under CPLR 3211 (a) (3), finding that collection litigation for services rendered in New Jersey did not establish systematic New York business activity. It denied discovery on capacity as moot. The provider's summary judgment cross motion and request under CPLR 3212 (g) were also denied. The insurer's denial documents raised a factual issue concerning compliance with 11 NYCRR 65-3.8 (a) (1), and the provider failed to establish a prima facie case because its assignment identified a different accident. Each side therefore defeated the other's request for dispositive relief.
