Key Takeaway
Court upholds $4,000 to $645.90 fee schedule reduction for CPT code 20553, explaining Ground Rule methodology and potential carrier recoupment analysis.
Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 2015 NY Slip Op 50778(U)(App. Term 2d Dept. 2015)
“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 affidavit submitted by defendant was 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 $645.90. It is of no relevance to the determination of this appeal that defendant has described a potential alternate calculation which, had defendant used it, would have concluded that only $416.85 was due.”
It is so nice to see the Court mention codes by number and to explain their methodology for reaching a given conclusion that the reduction is correct. Now I am curious how much money the carrier would recoup if they brought an unjust enrichment claim against Alleviation/ Guiterrez for the difference between $645,90 and $416,85 that was paid.
Assume there were 5000 claims with this pattern. That would be $1,145,250.
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Legal Update (February 2026): The fee schedule provisions and Ground Rules referenced in this 2015 case have been subject to multiple regulatory amendments since publication. Practitioners should verify current reimbursement rates under 11 NYCRR 65-3 and applicable Ground Rule calculations, as both CPT code valuations and reduction methodologies may have been substantially modified in the intervening period.
