Key Takeaway
New York Appellate Term denies insurer's motion to dismiss acupuncture provider's claim for initial session, reinforcing provider rights under no-fault law.
New York’s no-fault insurance system requires insurers to promptly pay for medically necessary treatment, including acupuncture services. However, insurance companies frequently attempt to avoid payment by challenging various aspects of healthcare provider claims. One common tactic involves filing motions to dismiss claims for initial acupuncture sessions, often arguing that proper documentation wasn’t provided or that fees exceed allowable rates under the workers’ compensation fee schedule.
The workers’ compensation fee schedule serves as the payment standard for many no-fault treatments, including acupuncture services covered under CPT codes 97813 and 97814. When insurers challenge these claims, they must provide substantial evidence to support dismissal. This case demonstrates the courts’ scrutiny of such challenges, particularly when insurers fail to adequately prove their contentions about excessive billing or insufficient documentation.
Understanding the relationship between no-fault insurance law and fee schedule requirements is crucial for both providers and patients navigating these disputes.
Jason Tenenbaum’s Analysis:
Perfect Point Acupuncture, P.C. v Clarendon Ins. Co., 2012 NY Slip Op 50399(U)(App. Term 2d Dept. 2012)
“That affidavit, however, was sufficient neither to warrant the dismissal of plaintiff’s claim for the initial acupuncture visit of April 18, 2006 (see Raz Acupuncture, P.C. v [*2]AIG Indem. Ins. Co., 28 Misc 3d 127, 2010 NY Slip Op 51177 ) nor to establish defendant’s contention that the amounts that had been charged by plaintiff for the acupuncture services rendered exceeded the relevant rates set forth in the workers’ compensation fee schedule”
Key Takeaway
The Appellate Term’s decision reinforces that insurance companies cannot simply file affidavits making broad assertions to dismiss acupuncture claims. They must provide concrete evidence showing either inadequate documentation or excessive billing compared to fee schedule requirements. This ruling protects healthcare providers’ rights to payment for legitimate initial acupuncture sessions and sets a higher standard for insurer dismissal motions.
Legal Update (February 2026): Since this post’s publication in 2012, New York’s no-fault fee schedules and reimbursement rates have undergone multiple revisions, including updates to workers’ compensation fee schedules that serve as payment standards for acupuncture services. Additionally, regulatory changes may have affected documentation requirements and claim processing procedures for initial acupuncture sessions. Practitioners should verify current fee schedule provisions and procedural requirements, as rates and documentation standards have likely been modified over the intervening years.
