Key Takeaway
Insurance companies must properly submit fee schedules as evidence when denying acupuncture claims, or risk having their payment denials overturned by courts.
No-fault insurance disputes often hinge on technical procedural requirements that can make or break a case. One critical aspect involves the proper submission of evidence when insurance companies seek to limit payments based on regulatory fee schedules. This is particularly important in acupuncture cases, where specific CPT codes like 97813 and 97814 govern billing procedures.
The workers’ compensation fee schedule sets maximum reimbursement rates for various medical services, including acupuncture treatments provided by chiropractors. When insurance companies deny portions of claims based on these fee schedules, they must properly establish their legal foundation through appropriate evidence submission. Understanding the 120-day rule and fee schedule requirements becomes crucial for both providers and insurers navigating these disputes.
Jason Tenenbaum’s Analysis:
Apple Tree Acupuncture, P.C. v Allstate Ins. Co., 2013 NY Slip Op 50413(U)(App. Term 2d Dept. 2013)
“In the instant case, defendant failed to establish, as a matter of law, that the amount it had paid plaintiff was the maximum amount permitted by the workers’ compensation fee schedule for acupuncture services rendered by a chiropractor and that defendant had properly denied the remaining portion of each of the claims at issue.”
If you do not put the fee schedule in your papers or seek judicial notice of same, dire consequences may arise.
Key Takeaway
Insurance companies cannot simply assert that fee schedule limits justify claim denials without properly submitting the actual fee schedule as evidence or requesting judicial notice. This procedural oversight can result in courts ruling against insurers even when the underlying fee schedule might support their position. Proper evidence submission remains fundamental to successful New York no-fault insurance law practice.
Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance fee schedules and workers’ compensation reimbursement rates have undergone multiple regulatory updates and amendments. The specific fee amounts, CPT code valuations, and procedural requirements for evidence submission in acupuncture reimbursement disputes may have been substantially modified through regulatory changes. Practitioners should verify current fee schedule provisions and evidentiary requirements under the most recent New York Insurance Department regulations and workers’ compensation board amendments.
