CPT Code 97026

Court Protects Healthcare Providers’ Rights to Bill for Infrared Therapy Services

CPT code 97026 represents infrared therapy, a treatment modality that insurance carriers frequently challenge as being outside the scope of covered services under New York No-Fault Insurance Law. However, a recent Appellate Term decision demonstrates that courts continue to scrutinize insurers’ attempts to categorically deny these claims without proper justification.

The case involved New Age Acupuncture challenging 21st Century Insurance Company’s denial of infrared therapy billing. Insurance carriers often deny CPT code 97026 claims by arguing the treatment falls “out of scope” of covered no-fault benefits, similar to disputes seen with other treatment codes like CPT codes 97813 and 97814 for acupuncture services.

This decision reinforces the principle that insurers must meet their burden when seeking summary judgment to dismiss provider claims, particularly when medical necessity disputes are involved.

Jason Tenenbaum’s Analysis:

New Age Acupuncture, P.C. v 21st Century Ins. Co., 2016 NY Slip Op 50737(U)(App. Term 2d Dept. 2016)

“Upon a review of the record, we find that defendant’s moving papers failed to demonstrate defendant’s prima facie entitlement to summary judgment with respect to so much of the complaint as sought to recover for services billed using CPT code 97026 (Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132, 2009 NY Slip Op 50732 ; see generally Sunrise Acupuncture PC v Tri-State Consumer Ins. Co., 42 Misc 3d 151, 2014 NY Slip Op 50435 ).

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed using CPT code 97026 is denied.”

This would be the infrared code. I suspect the insurance carrier denied the billing as “our of scope”. The recent case law would suggest otherwise and this is just a further elucidation of the recent case law.

Key Takeaway

The Appellate Term’s reversal reinforces that insurance companies cannot simply dismiss infrared therapy claims without meeting their burden of proof. This decision continues the trend of courts protecting healthcare providers’ billing rights for legitimate therapeutic modalities, emphasizing that carriers must provide substantial justification when denying coverage for established treatment codes.

Legal Update (February 2026): Since this 2016 post, New York’s no-fault fee schedules and reimbursement rates for physical therapy services, including CPT code 97026, have been subject to multiple regulatory updates and amendments. Practitioners should verify current fee schedule provisions, coverage parameters, and any procedural changes that may affect infrared therapy billing under the no-fault system.