CPT Code 20553 reduced from $4,000 to less than $1,000

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 2015 NY Slip Op 50379(U)(App. Term 2d Dept. 2015)

First off, good job to Linda Filosa, Esq from Richard Lau’s office on an impressive affirmance.  These fee schedule issues in many ways are sui generis and each raise issues of first impression.

Second, this case explains the methodology of how you get from a BR report code (CPT Code 20553 ) to a scheduled use Code (CPT code 20552) with the application of the 50% reduction of Ground Rule 5.

Third, in the pre 2013 fee schedule precludability era, this case describes how box #18 being checked is (shall we say) the be all and end all of the analysis.

Good win for State Farm!!

Plaintiff’s main argument on appeal with respect to defendant’s cross motion is that defendant failed to demonstrate that it had properly reduced the sum billed for CPT code 20553 from $4,000 to $645.90 pursuant to the workers’ compensation fee schedule. Contrary to plaintiff’s contention, the affidavits submitted by defendant were sufficient to demonstrate, prima facie, that Ground Rule 3 and Ground Rule 5 were appropriately applied to the services billed, and that defendant properly applied CPT code 20552 in order to determine the amount due, which it calculated to be $592.07. Defendant’s employee explained that defendant had mistakenly paid $645.90 for 21 trigger point injections rather than $592.07 for the 20 injections for which plaintiff had billed. In any event, it is of no relevance to the determination of this appeal that defendant paid an additional $53.83 as a result of this mistake, or that it has described a potential alternate calculation which, had defendant used it, would have concluded that only $416.85 was due. Defendant has demonstrated that it paid more than it was responsible for pursuant to the workers’ compensation fee schedule, and plaintiff has not rebutted that showing. Contrary to plaintiff’s second argument on appeal with respect to defendant’s cross motion—that defendant’s proffered defense was not set forth in its denial—a checked box on the denial of claim form indicated that benefits were denied because the fees were not in accordance with the fee schedule, and the denial referenced an attached “Explanation of Review.”

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Legal Update (February 2026): Since 2015, New York’s no-fault fee schedules and Ground Rules have undergone multiple revisions, including updates to CPT code valuations, reimbursement methodologies, and procedural requirements. The specific fee calculations, Ground Rule applications, and CPT code conversions discussed in this case may no longer reflect current schedule provisions. Practitioners should verify current fee schedule amounts and applicable Ground Rules when handling similar reimbursement disputes.