Non acupuncture based add on codes – issue of fact

2 & 9 Acupuncture, P.C. v 21st Century Advantage Ins. Co., 2017 NY Slip Op 50599(U)(App. Term 2d Dept. 2017)

“Upon a review of the record, we find that defendant failed to demonstrate, prima facie, that it had properly denied payment for the unpaid portions of the bills for services billed under CPT codes 97026 and 97016 in accordance with the workers’ compensation fee schedule (see Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129, 2016 NY Slip Op 51359 ; W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co., 36 Misc 3d 133, 2012 NY Slip Op 51335 ).

Accordingly, the amended order, insofar as appealed from, is reversed and the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT codes 97026 and 97016 are denied.”

It appears that Plaintiff billed for the above two codes and was not compensated for the same.  The Court through citing Sama Physical and WHO Acupuncture, P.C. is holding that in order  to zero out the non acupuncture based codes, an expert affidavit is necessary (WHO Acupuncture).  Alternatively, more probative proof would be necessary should Ground Rule 11 be utilized (Sama),

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• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2017 post discussing fee schedule denials for CPT codes 97026 and 97016, New York’s workers’ compensation fee schedules and related regulations may have been amended or updated. Practitioners should verify current fee schedule provisions and denial procedures, as reimbursement rates and evidentiary requirements for challenging denials may have changed.