Fee Schedule Defense Requirements in No-Fault Insurance Cases | Long Island & NYC Legal Analysis

Understanding Fee Schedule Defenses in New York No-Fault Insurance Cases

A denial stating that a bill exceeds the fee schedule is not proof of the calculation. That was the problem with the seventh cause of action in St. Vincent Medical Care v Country Wide, 2010 NY Slip Op 50488(U), decided March 19, 2010. The insurer attached no evidence supporting that defense, so the provider retained its recovery on that claim. The insurer prevailed on other claims because verification remained outstanding.

Legal Update (September 2026): This note predates the April 1, 2013 excessive-fee amendment to 11 NYCRR 65-3.8(g); Precious Acupuncture v Hereford (2018) applied it to preserve a fee-schedule defense without proof of a timely denial, while requiring evidence of the payment calculation, as discussed in the certified-coder case note.

What the 2010 decision established

The insurer’s fee defense failed for lack of proof; the court did not hold that every billed service was separately reimbursable. The opinion did not identify the disputed service as range-of-motion testing. Jason’s original explanation was expressly tentative:

This is probably regarding a global denial based upon range of motion testing being considered part of the initial visit. I do not know this for sure, but this seems to be a common theme between these parties and the attorneys representing them. Today, the Appellate Term properly held that an issue of fact was not raised. On some days, they hold a triable issue of fact is raised when similar proof is presented. On other days, they hold similar to that of this case.

The opinion also left the tenth, medical-necessity cause of action outside the appeal. The insurer had not appealed the underlying order, and the judgment being reviewed did not bring that branch up for review.

Jason’s original observation on the appeal

The following is the original 2010 commentary, not an unrestricted statement of today’s appellate rule. In particular, “always” is too broad: CPLR 5501(a)(1) concerns an unreviewed nonfinal order or judgment that necessarily affects the final judgment.

It took me a bit to figure this out. A final judgment always brings up for review the underlying non-appealed interlocutory orders. In this case, an interlocutory judgment was issued, since the judgment did not encompass the entire action. Rather, it encompassed everything except the medical necessity cause of action. Therefore, absent an appeal of the order denying summary judgment, Defendant can only appeal from the final judgment. The final judgment would occur following the trial. At that point, an appeal of the final judgment would bring up for review the order denying summary judgment.

Do you understand?

Latest developments and limits of the older cases

• 2026 — a surviving fee defense still needed a trial. In Burke Physical Therapy v National General, 2026 NY Slip Op 30876(U), Kings County Civil Court rejected the IME defense on four claims but sent their fee-schedule defense to trial. Nonpreclusion did not establish the correct reimbursement.
• 2025 — a contrary trial-level interpretation. In Blano Medical v Hereford, 2025 NY Slip Op 51540(U), Kings County Civil Court rejected the insurer’s attempt to assert a fee defense at trial without a denial. That decision should not be presented as overruling the appellate holding in Precious Acupuncture. The differing treatments warrant attention to court, posture and later history.
• 2020 — different schedules for later services. The 35th Amendment to Regulation 83 made the specified 2018 and 2019 workers’ compensation schedule amendments applicable to no-fault services from October 1, 2020. The older acupuncture-rate and eight-unit notes below are historical records, not instructions for pricing today’s treatment.
• 2016 — office-based facility fees. GEICO v Avanguard, 27 NY3d 22 held that the statutory and regulatory framework did not mandate separate office-based surgery facility fees. Read the archive’s earlier Upper East Side Surgical note with that later Court of Appeals decision.

Questions to separate before using a fee-schedule case

Does a late denial automatically defeat the fee defense?

Not under the post-2013 appellate treatment described above. Service dates matter, and a preserved defense still needs proof. A ruling about excessive fees should not be applied indiscriminately to a different defense, such as lack of medical necessity.

Must the insurer use a particular kind of witness?

St. Vincent did not prescribe a universal witness qualification. Precious Acupuncture accepted a certified coder’s affidavit on its record. The question is whether the evidence explains the applicable schedule, codes and calculation; a job title alone does not supply that explanation.

Can the provider simply charge the patient the difference?

Insurance Law § 5108(c) prohibits demanding payment beyond the charges authorized by that section. A dispute over an insurer’s calculation is not, by itself, permission to balance-bill the patient.

Cases in this topic

These dated notes trace the fee-schedule disputes in the archive. They are not a current rate chart. Read each with the service date, provider type and later authorities in mind. Florida comparisons and older regulatory announcements are separated below.

Proof, coders and judicial notice

• Fee-schedule arithmetic and proof of code selection — 2021-05-22.
• LVOV Acupuncture: the coder’s explanation of the payment — 2021-03-17.
• Sama Physical Therapy: a certified coder’s calculation — 2019-11-24.
• Global Liberty v McMahon: CPT Assistant in arbitration — 2019-05-12.
• Precious Acupuncture: the certified coder’s affidavit — 2018-01-19.
• Laga: conversion factors and Ground Rule 11 — 2017-12-26.
• Adelaida Physical Therapy: proving the conversion factor — 2017-12-26.
• Jaga Medical Services: coder proof and the separate necessity defense — 2017-07-31.
• Gentle Acupuncture: explaining the schedule interpretation — 2017-06-10.
• Acupuncture Healthcare Plaza v Metlife: limits of judicial notice — 2017-02-20.
• Renelique v American Transit: relative value and conversion factor — 2016-10-27.
• GBI Acupuncture: the professional coder’s affidavit — 2015-08-24.
• Healing Art v Amica: the fee-schedule vendor’s affidavit — 2015-02-11.
• Apple Tree Acupuncture: proof of the allowable payment — 2013-04-01.
• MIA Acupuncture v Praetorian: the submitted proof and judicial-notice dissent — 2012-04-25.
• MIA Acupuncture v Integon: documenting fee-schedule payment — 2012-03-12.
• Z.A. Acupuncture: incorporation by reference and judicial notice — 2011-10-19.
• OS Tigris Acupuncture: competent evidence of a fee-schedule defense — 2008-10-11.

Acupuncture reimbursement and the older rate disputes

These notes concern the older chiropractor-rate approach, not a current acupuncture fee chart. A separate acupuncture schedule took effect for no-fault services in October 2020.

• Mind & Body Acupuncture: payment under the chiropractor schedule — 2022-07-13.
• S.O.V. Acupuncture: the older schedule and billed codes — 2020-09-25.
• Culex Acupuncture: inconsistent payments and estoppel — 2017-09-21.
• Health Needles Acupuncture: a challenge to the schedule reduction — 2015-01-03.
• Karina K. v State-Wide: fee calculations and mailing proof — 2014-10-28.
• Okslen Acupuncture: the physician-rate payment record — 2014-08-13.
• Healthy Way Acupuncture: schedule excerpts and the rate calculation — 2014-08-06.
• Ema Acupuncture: applying Great Wall to the payment record — 2014-03-25.
• Lotus Acupuncture: payment calculations and denial mailing — 2013-11-26.
• Akita Medical Acupuncture: the First Department’s rate cases — 2013-11-18.
• GL Acupuncture: applying the chiropractor schedule to the billed codes — 2013-10-27.
• Acupuncture Approach v MVAIC: the constitutional challenge — 2013-05-13.
• Oriental World Acupuncture: the Great Wall reversal — 2012-06-18.
• Raz Acupuncture v New South: evidence of full payment — 2012-05-16.
• W.H.O. Acupuncture: the rate challenge and judgment procedure — 2011-08-05.
• Sung Bok Lee: administrative interpretation of reimbursement rules — 2011-02-03.
• Historical commentary on judicial treatment of agency fee interpretations — 2011-01-25.
• Natural Acupuncture Health: payment under the chiropractor schedule — 2011-01-20.
• Gentle Care Acupuncture: rate, initial-visit and medical-necessity issues — 2010-12-27.
• Raz Acupuncture v AIG: the rate paid and the remaining claims — 2010-07-08.
• Great Wall Acupuncture (2009): prima facie proof and the chiropractor rate — 2009-11-19.
• Great Wall Acupuncture (2009): payment under the chiropractor schedule — 2009-11-18.
• The older chiropractor-rate cases and acupuncture reimbursement — 2009-11-05.
• AVA Acupuncture: the reimbursement-rate dispute — 2009-05-29.
• Forrest Chen Acupuncture: deference to the insurance regulator — 2008-10-11.

Evaluation codes, add-on codes and down-coding

• Live In Grace Acupuncture: CPT 97813 and 97814 — 2021-03-17.
• Healing Art Acupuncture: coding the acupuncture session — 2019-04-24.
• Urban Well Acupuncture: down-coding the billed services — 2018-12-18.
• Z. M. S. & Y Acupuncture: separating CPT 97811, 97813 and 97814 — 2017-12-26.
• Charles Deng v State Farm: evaluation and consultation codes — 2017-11-04.
• Charles Deng v 21st Century: acupuncture codes and discovery — 2017-10-02.
• Compas Medical: proof concerning CPT 64550 — 2017-10-02.
• Acupuncture Approach: the CPT 97039 scope-of-practice defense — 2017-09-21.
• 2 & 9 Acupuncture: CPT 97026 and 97016 proof — 2017-05-11.
• New Age Acupuncture: the proof offered for CPT 97026 — 2016-05-13.
• VS Care Acupuncture: CPT 97039 and 97026 — 2015-03-19.
• Shara Acupuncture: distinguishing the initial evaluation claim — 2013-10-27.
• Flushing Traditional Acupuncture: the unaddressed initial evaluation — 2013-09-25.
• Perfect Point Acupuncture: the initial-visit claim — 2012-03-12.
• Olga Bard Acupuncture: treatment codes and the initial consultation — 2010-11-14.

By-report billing, trigger-point codes and separately billed testing

• Bronx Acupuncture Therapy: by-report billing and verification — 2019-08-10.
• Pavlova: requesting documentation for CPT 20999 — 2018-11-25.
• The 2017 by-report appeal: Jason’s preliminary commentary — 2018-01-02.
• CPT 97039: requesting the supporting report — 2017-12-26.
• Renelique v Allstate: the CPT 20553 calculation — 2017-09-21.
• Alleviation Medical Services: another note on the older CPT 20553 reduction — 2015-05-27.
• Alleviation Medical Services: CPT 20553 and the ground rules — 2015-04-07.
• First Aid Occupational Therapy: the bundled-service defense — 2010-04-13.
• St. Vincent Medical Care (2010): competing views of testing charges — 2010-03-18.
• St. Vincent Medical Care (2009): separately billed testing — 2009-12-20.

Denial wording and the 2013 excessive-fee amendment

• Oleg’s Acupuncture: the post-2013 preclusion rule — 2018-01-26.
• Acupuncture Healthcare Plaza: fee-denial notice and separate fraud proof — 2017-07-31.
• Global Liberty v Therapeutic Physical Therapy: denial specificity — 2017-03-16.
• Easy Care v ELRAC: pre-2013 services and a late denial — 2017-02-25.
• Renelique v Tri State: the wording of the fee denial — 2016-06-10.
• Tyorkin: the NF-10 form and the excessive-fee exception — 2016-06-03.
• Saddle Brook Surgicenter: the 2013 amendment and New Jersey fees — 2015-04-08.
• Denial forms and explanations of benefits: notice of a fee defense — 2012-05-05.
• Mercury v Encare (2011): the pre-amendment denial dispute — 2011-08-11.
• Jason’s historical discussion of fee defenses in the Law Journal — 2010-09-29.

Daily-unit limits and payments to other providers

• NL Quality Medical: the foundation for fee-schedule documents — 2021-03-17.
• Easy Care Acupuncture v MVAIC: unit limits and other-provider payments — 2016-10-27.
• Liberty Chiropractic: authenticating other-provider payment records — 2016-10-13.
• TC Acupuncture: daily-unit and medical-necessity issues — 2016-06-30.
• Doctor of Medicine in the House: the eight-unit dispute — 2013-10-27.

Out-of-state treatment and office-based facility fees

The 2012 Upper East Side note predates the Court of Appeals’ 2016 Avanguard decision discussed above; the 2016 rulemaking note describes a proposal, not proof of adoption.

• Excel Surgery Center: New Jersey fees and preclusion — 2019-11-24.
• The 2016 proposed amendment to out-of-state reimbursement — 2016-09-30.
• Surgicare (2015): the appellate ruling on New Jersey fees — 2015-10-12.
• Avanguard (2015): the Appellate Division’s office-based facility-fee ruling — 2015-02-19.
• Surgicare (2014): the trial court’s New Jersey schedule analysis — 2014-11-26.
• Epic Pain Management: identifying the provider’s geographic location — 2014-09-17.
• Upper East Side Surgical (2012): the earlier office-based facility-fee ruling — 2012-02-03.

Equipment rentals and manipulation-under-anesthesia billing

• Global Liberty v ISurply: CPM rentals and informal agency guidance — 2018-07-07.
• High Quality Medical Supplies: equipment missing from the schedule — 2016-10-13.
• Accelerated DME Recovery: the earlier CPM rental dispute — 2016-02-26.
• Historical arbitration note on MUA-related billing codes — 2012-06-21.
• Flatbush Chiropractic (2012): the MUA payment dispute — 2012-03-28.
• Giugliano (2010): manipulation-under-anesthesia billing — 2010-08-06.

Related billing dispute: whether the service was performed

• Karina K. Acupuncture: whether needle reinsertion was performed — 2018-06-25.

Historical commentary and regulatory announcements

The two eight-unit announcements belong together: the later post says the earlier informal PT-rules email was not the Board’s official position. Neither email is a substitute for the applicable schedule.

• Changes to the medical fee schedule and delayed no-fault implementation — 2019-01-15.
• The 2018 notice withdrawing an informal PT-rules position — 2018-04-23.
• An earlier eight-unit interpretation, before the withdrawal notice — 2018-02-14.
• Jason’s first encounter with billing code G0283 — 2014-10-07.
• Jason’s historical commentary on acupuncture fee arguments — 2011-09-26.

Florida comparisons — not New York reimbursement rules

• Florida fee schedules and reasonable-charge evidence — 2022-07-30.
• Hands On Chiropractic: Florida PIP and a below-schedule bill — 2021-09-11.
• Hallandale Beach Orthopedics: Florida Medicare-based reimbursement — 2021-08-21.

Connect to the Encyclopedia

Return to the Legal Encyclopedia’s no-fault topics. For the closest companion notes:

• St. Vincent’s earlier dispute over separately billed testing.
• Precious Acupuncture and the certified coder’s affidavit.
• Oleg’s Acupuncture and the post-2013 preclusion rule.
• Judicial notice does not establish the fee calculation.
• The by-report verification dispute in Bronx Acupuncture Therapy.
• The initial application of the excessive-fee amendment.

Contact an Experienced No-Fault Insurance Attorney

For help reviewing a fee-schedule dispute, contact the Law Office of Jason Tenenbaum or call (516) 750-0595. Bring the bills, service dates, denial forms and payment calculations.