Key Takeaway
Pavlova's by-report documentation ruling: why Allstate's motion failed, why the provider also lacked judgment, and limits of the repricing commentary.
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
Historical note: Pavlova (2018) concerns a missing-documentation denial without the necessary request. It does not supply blanket authorization for partial repricing.
Last reviewed: September 2026
Pavlova v. Allstate rejected a denial based on missing by-report documentation that the insurer had not requested. It did not announce a blanket right to reprice a BR code whenever an insurer makes a partial payment. Both sides remained without summary judgment on the disputed CPT 20999 claim.
What the court decided about documentation
The 2018 opinion required an additional-verification request within 15 business days in the circumstances before it. Allstate had denied the entire BR-coded claim for insufficient documentation without showing that it requested the missing material. The Appellate Term denied that branch of Allstate’s motion. The provider’s own motion remained denied because its initial showing was insufficient.
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Jason’s retained commentary distinguishes documentation denials from reductions supported by information already held. That is his analysis, not a holding that partial payment excuses every verification obligation. The ground for the denial and the evidence supporting the proposed amount still matter.
DFS’s guidance on BR services calls for a written report supporting the service and charge. The 2019 Bronx Acupuncture note follows the verification issue to a later appellate decision; it concerns a different claim.
Jason’s historical commentary
Jason’s original interpretation is retained as commentary. The broader repricing proposition and criticism of arbitrators are not findings or categorical rules announced in Pavlova:
This is an interesting case since several arbitrators have been lulled into finding that Bronx Acupuncture stands for the proposition that an insurance carrier ma not re-price a code labelled “BR” without resort to verification. Bronx Acupuncture means what it says – you cannot deny a bill based upon the non-compliance with the by report requirements. Should the carrier believe it has sufficient information to re-price a service, then this defense will stand despite not following the by-report protocols. Yet, we shall still see too many arbitrators refusing to follow the law.
Connect to the Encyclopedia
- Fee-schedule defense hub: cases, proof and later developments
- Bronx Acupuncture: leave to appeal was not a merits ruling
- Bronx Acupuncture (2019): the later verification decision
- St. Vincent: verification and the later reversal
- Jodi Jacobs: the code-selection proof gap
- Down-coding: the rule and evidence for a reduction
For review of a particular no-fault billing dispute, contact our office.
Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
118 published articles in Fee Schedule
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
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