Initial visit compensable

The initial-evaluation claim survived, but Shara Acupuncture did not receive a payment award on that claim. Allstate had established full scheduled payment for the treatment codes and failed to address the separate evaluation code. The appellate court corrected that overbroad dismissal while leaving the provider’s own request for summary judgment denied.

Legal Update (September 2026): Shara applied the older acupuncture payment framework; the later schedule amendments apply to no-fault services from October 1, 2020, while its code-by-code motion result remains a dated comparison in the fee-schedule hub.

Last reviewed: September 2026.

The two parts of the October 2013 decision

Shara Acupuncture, P.C. v Allstate Insurance Co., 2013 NY Slip Op 51731(U), was decided October 8, 2013, by the Appellate Term, Second Department. The provider appealed from an order denying its motion for summary judgment and, after the Civil Court searched the record, dismissing its complaint in the insurer’s favor.

The treatment claims were billed under CPT 97810 and 97811. Allstate established full payment under the workers’ compensation schedule then used for acupuncture services performed by chiropractors. The appellate court left dismissal of those treatment claims intact.

The separate CPT 99203 initial evaluation was different. Allstate had not addressed it in its motion proof. The court therefore deleted the part of the order dismissing that claim. A finding about the treatment charges did not dispose of an additional code the insurer had left unexplained.

Why neither side won the evaluation claim

Allstate’s omission did not automatically establish the provider’s entitlement to judgment. The insurer had shown that the evaluation claim was timely denied. Shara did not establish that the denial was conclusory, vague or without merit as a matter of law.

The result left the evaluation claim unresolved. It did not set a reimbursement amount, declare every initial evaluation separately payable or direct immediate payment. The historical title, “Initial visit compensable,” is best understood in that narrower procedural context.

The published decision thus requires two separate readings: what proof defeated the insurer’s request for dismissal, and what proof was missing from the provider’s own motion. Treating those questions as opposites would turn the absence of one side’s proof into affirmative proof for the other.

Jason’s original reaction

Jason’s short October 2013 comment captured the recurring problem of an overlooked evaluation code:

That damned initial code again.

The reaction remains part of the note’s history. The explanatory copy now identifies the unresolved claim rather than saying that the provider recovered simply because the insurer overlooked it.

Read the bill against the requested order

A useful way to examine Shara is to compare each billed code with the relief requested. An insurer asking to dismiss the whole complaint needs a basis for disposing of the claims included in that request. Here, the proof described the treatment codes but did not address the initial evaluation.

That does not create a rule that every motion must use a particular spreadsheet or witness. It explains the mismatch in this record. A general statement that the carrier paid the acupuncture treatments did not answer what happened to the separately billed evaluation.

The same distinction helps a provider identify what remains in dispute. If treatment claims have been dismissed and one evaluation claim remains, the live issue is not the value of the entire course of treatment. It is the surviving claim and the grounds on which that claim can be proved or defended.

For the other side of the comparison, MIA Acupuncture v Integon records a complete insurer victory after proof of full scheduled payment and timely denials. Healing Art v Amica identifies the vendor evidence accepted for the calculation. Those cases are useful companions because they show what a successful payment record established.

The fee schedule is tied to the service date

Shara should not be used as a current price list for 97810, 97811 or 99203. The 35th Amendment to Regulation 83 changed the no-fault adoption date for the specified workers’ compensation schedule amendments to October 1, 2020.

The applicable schedule, provider type and ground rules must be identified for a later service. An old opinion’s reference to a chiropractor schedule does not establish that a particular modern acupuncture bill should receive that rate. Nor does this opinion identify the profession of each person who performed the historical services merely by naming the schedule.

Denial timing presents a separate date issue. Shara expressly addressed timely denial; the Saddle Brook note on the excessive-fee amendment addresses how the later-described fee-preclusion exception operated for post-April 1, 2013 services. A reader should not infer the service date from the date a decision was published.

What this case can and cannot answer

Shara can answer why an insurer’s success on the main treatment codes did not justify dismissal of an unaddressed initial-evaluation claim. It also shows why the provider still needed to establish its own entitlement to summary judgment.

It cannot answer whether a new evaluation was medically necessary, whether a current code was properly selected, or what amount another bill should receive. Those questions require the actual clinical and billing record and the rules applicable to that service.

For a patient reviewing a provider’s bill, the appellate result is not a determination of personal responsibility for an unpaid balance. Insurance Law § 5108(c) limits demands beyond the authorized charges. The assignment, denial and reason for the disputed amount need to be read before drawing conclusions from a case headline.

Connect to the Encyclopedia

Start with the fee-schedule defense hub. Follow the closest case comparisons:

• MIA Acupuncture: full scheduled payment supported dismissal.
• Healing Art: a vendor’s affidavit established the fee calculation.
• Natural Acupuncture Health: different claims had different outcomes.
• Saddle Brook: service dates and the excessive-fee amendment.
• Tyorkin: an unresolved fee calculation went to trial.

For review of a particular no-fault billing dispute, contact the Law Office of Jason Tenenbaum. Bring the service dates, bills, payment records, denials and the insurer’s fee calculation. A review can identify the disputed issue; these historical decisions do not guarantee a recovery.