Key Takeaway
Court upholds insurer's application of workers' compensation fee schedule to CPT code 20553, highlighting ongoing disputes over proper billing methodologies in no-fault cases.
Court Affirms Proper Application of Fee Schedule to CPT Code 20553
The ongoing complexity of New York No-Fault Insurance Law frequently centers on disputes over proper billing methodologies and fee schedule applications. CPT code 20553, which relates to injection procedures for trigger point therapy, has been a particular source of contention between medical providers and insurance carriers. Understanding how courts interpret the application of fee schedules to specific medical procedures is crucial for both healthcare providers and insurers navigating the no-fault system.
The Appellate Term’s decision in Renelique v Allstate Insurance Co. provides important guidance on the burden of proof required when challenging an insurer’s fee schedule calculations, particularly regarding injection procedures that may require specific documentation or manipulation techniques.
Jason Tenenbaum’s Analysis:
Renelique v Allstate Ins. Co., 2017 NY Slip Op 51141(U)(App. Term 2d Dept. 2017)
“Contrary to plaintiff’s argument, defendant demonstrated that it had properly applied the workers’ compensation fee schedule to calculate the amount due for services billed under CPT code 20553, and plaintiff failed to rebut defendant’s showing (cf. Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 47 Misc 3d 149, 2015 NY Slip Op 50778 ).”
I am unsure if this is pre or post FS amendment to code 20553. The c.f. citation is interesting, if it is presupposes that the older version of 20553 required manipulation to achieve the desired result.
Key Takeaway
This decision reinforces the principle that medical providers challenging an insurer’s fee schedule application bear the burden of demonstrating improper calculation. The court’s reference to Alleviation Medical Services suggests ongoing evolution in how courts interpret billing requirements for injection procedures, similar to disputes seen with other CPT codes like 97026 and the broader 120-day rule framework governing fee schedule disputes.
Legal Update (February 2026): Since this 2017 post, New York’s no-fault fee schedules and workers’ compensation reimbursement rates referenced for CPT code 20553 may have been subject to regulatory amendments or updated calculation methodologies. Additionally, procedural requirements for documentation of injection procedures and burden of proof standards in fee schedule disputes may have evolved through subsequent case law or regulatory changes. Practitioners should verify current fee schedule provisions and recent appellate decisions when handling similar reimbursement disputes.
