Key Takeaway
Insurance companies must properly submit fee schedules as evidence when denying acupuncture claims, or risk having their payment denials overturned by courts.
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
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.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
118 published articles in Fee Schedule
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May 22, 20218 units per diem – the Workers Compensation Board has spoken
Workers Compensation Board clarifies 8-unit daily limit rule for PT treatments in NY no-fault insurance cases - CMT codes don't count toward non-chiro limits.
Feb 14, 2018The DME equivalent of Robert Physical Therapy plays out
New York court rules that DME not included in fee schedules can still be compensable under 11 NYCRR 68.5, overturning insurance carrier arguments.
Oct 13, 2016Acupuncture fee schedule from the First Department
First Department ruling on acupuncture fee schedules in no-fault insurance cases, analyzing chiropractor rate limitations and prima facie defense requirements.
Nov 18, 2013Another case where the Appellate Term seems to hold that a triable issue of fact is raised regarding the compensability of range of motion testing
Appellate Term ruling creates triable issue of fact regarding separate reimbursement for range of motion testing versus inclusion in office visit services.
Apr 13, 2010Common Questions
Frequently Asked Questions
What is the no-fault fee schedule?
New York's no-fault fee schedule, established by the Workers' Compensation Board and the Department of Financial Services, sets the maximum reimbursement rates that no-fault insurers must pay for medical services. When an insurer pays less than the billed amount, citing the fee schedule as a defense, the provider can challenge the reduction by demonstrating that the fee schedule was improperly applied or that the services are not subject to fee schedule limitations.
Can a medical provider charge more than the fee schedule allows?
Medical providers treating no-fault patients are generally limited to the amounts set by the fee schedule and cannot balance-bill the patient for the difference. However, certain services may not be covered by the fee schedule, and disputes about whether a specific service falls within the fee schedule are common in no-fault litigation. The Department of Financial Services periodically updates the fee schedule rates.
How are fee schedule disputes resolved in no-fault arbitration?
When an insurer partially pays a claim citing the fee schedule, the provider can challenge the reduction through no-fault arbitration. The provider must demonstrate that the service billed is not subject to the fee schedule or that the fee schedule was incorrectly applied. The insurer bears the burden of proving the fee schedule applies and the correct rate was used. Fee schedule disputes often involve coding issues, modifier usage, and applicability of Workers' Compensation rates.
Does the no-fault fee schedule apply to all medical services?
Not all medical services are subject to the no-fault fee schedule. Certain services, supplies, and procedures may fall outside its scope, in which case the provider may bill the usual and customary rate. Disputes about whether a specific service or billing code is covered by the fee schedule are common. The Workers' Compensation Board fee schedule and the Department of Financial Services ground rules guide which services are covered and at what rates.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a fee schedule matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.