Key Takeaway
Court ruling highlights insurance companies must address initial evaluation codes separately from routine treatment codes in no-fault insurance disputes.
This case from New York’s Appellate Term demonstrates a common pitfall in New York no-fault insurance law disputes: insurance companies focusing solely on routine treatment codes while overlooking initial evaluation charges. The ruling in Shara Acupuncture, P.C. v Allstate Ins. Co. shows how incomplete defense strategies can backfire, even when insurers successfully defend against the bulk of a provider’s claims.
The case involved an acupuncture provider seeking payment for services under multiple billing codes. While the insurance company successfully defended against charges for routine acupuncture treatments by demonstrating proper payment under the workers’ compensation fee schedule, they failed to address a separate initial evaluation code - a mistake that cost them summary judgment on that portion of the claim.
Jason Tenenbaum’s Analysis:
Shara Acupuncture, P.C. v Allstate Ins. Co., 2013 NY Slip Op 51731(U)(App. Term 2d Dept. 2013)
“With respect to plaintiff’s claims for acupuncture services billed under codes 97810 and 97811, defendant demonstrated that it had fully paid plaintiff for those services in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 ). Accordingly, we do not disturb so much of the Civil Court’s order as, upon searching the record, awarded defendant summary judgment dismissing so much of the complaint as sought to recover for services billed under those codes. However, as defendant failed to address an “initial evaluation,” which had been billed under code 99203, defendant should not have been awarded summary judgment [*2]dismissing so much of the complaint as sought to recover the $75.11 that had been billed under that code.”
That damned initial code again.
Key Takeaway
Insurance companies must comprehensively address all billing codes in their defense, not just the primary treatment codes. Even a successful defense of major claims can fail if initial evaluation or consultation codes are overlooked, allowing providers to recover on those specific charges despite losing on their main treatment billing disputes.
Legal Update (February 2026): Since this 2013 post was published, New York’s no-fault fee schedules and reimbursement rates have been subject to multiple regulatory amendments and updates. Practitioners should verify current fee schedule provisions, billing code requirements, and reimbursement methodologies, as the specific rates and procedures referenced in this case analysis may no longer reflect current law.
