NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld

This note reports a 2009 trial. It is not a current acupuncture rate chart. In Great Wall Acupuncture v GEICO, 2009 NY Slip Op 29467, decided November 17, 2009, the Appellate Term, Second Department, affirmed judgment for the insurer.

Historical note: The chiropractor-rate ruling concerns the older schedule regime; DFS identifies the later acupuncture schedule adoption and October 2020 service-date rules, so this note’s historical headline is not a present-day universal rate cap.

Last reviewed: September 2026.

The trial record matters

The parties stipulated to the provider’s prima facie case and a timely denial. The claim form and denial were in evidence. The provider’s witness held both acupuncture and chiropractic licenses and testified about the training requirements. Payment at the applicable chiropractor-schedule amount was undisputed.

The court accepted use of that schedule for the licensed acupuncturist on this record. It did not hold that a provider can never dispute the selected code, calculation or governing schedule. Nor did it eliminate differences between professional licenses.

Why the old rate language needs a date

The Insurance Department’s 2004 opinion explained the older comparison with similar procedures in existing schedules when there was no adopted schedule for licensed acupuncturists. That historical premise is not a description of the schedules now available.

The separate August 2009 Great Wall appeal also shows why the outcome cannot be reduced to a slogan: the provider prevailed on one claim where timely denial had not been proved. Later excessive-fee preclusion rules require a separate service-date analysis.

Insurance Law § 5108(c) does not permit a provider to demand an unauthorized excess from the patient merely because the insurer paid less than the bill.

Jason’s historical commentary

The archive’s commentary below is broader than the reported holding. In particular, the claim that nothing can rebut the defense is not the court’s rule and should not be used for present-day billing: One retained sentence ends at the Law Journal reference; its missing continuation has not been reconstructed.

This case completes the equation as to what is necessary for a carrier that pays the chiropractor rate for acupuncture to prevail at trial. Upon showing that acupuncture services were paid at the chiropractor rate, a prima facie defense as a matter of law has been satisfied.

Thus, as long as the pertinent portions of the fee schedule and a timely §5106(a) denial are in evidence, a defense verdict should be granted. There is nothing that a plaintiff can do to rebut this prima facie showing

This portion of the opinion discusses the evidence that in the Appellate Term’s opinion was sufficient to make a prima facie demonstration that the acupuncture services were billed in excess of the chiropractor fee schedule.

Here, the Appellate Term outlined the comparative licensure requirements between a licensed acupuncturist and a chiropractor licensed to practice acupuncture. I would just note that Judge Gonzalez in Great Wall Acupuncture v. GMAC, 6/15/2007 N.Y.L.J.

Connect to the Encyclopedia

Start with the fee-schedule defense hub. Related case notes:

• Urban Well: coding corrections and separate necessity proof.
• OS Tigris: an unsupported fee-schedule defense.
• Great Wall: the split result in the August 2009 appeal.
• Live In Grace: the electrical-stimulation codes 97813 and 97814.
• Healing Art: agreed coder testimony on codes 97810 and 97811.
• Precious Acupuncture: coder proof and post-2013 preclusion.

For review of a particular no-fault billing dispute, contact the Law Office of Jason Tenenbaum. Bring the bill, service dates, denial and payment calculation.