The power of the certified medical coder

In LVOV Acupuncture v Nationwide (2020), the Appellate Term accepted a certified medical coder’s affidavit showing proper use of the fee schedule. The provider did not raise a triable issue, and dismissal was affirmed. The court did not require every opposing provider to hire another expert.

Historical note: LVOV (2020) accepted the coder’s proof in that record; it did not establish a current reimbursement rate or a universal requirement that a provider retain a counter-expert.

Last reviewed: September 2026

What the affidavit established

The insurer’s proof showed that it had properly used the workers’ compensation fee schedule to determine payment for the services at issue. The opinion relied on earlier fee-schedule cases, including Quality Comprehensive Medical Care and Sama Physical Therapy.

The court’s short explanation does not identify the coder’s credentialing organization, reproduce the calculation or specify the disputed procedure codes. Those details should not be supplied by inference. Nor does the opinion compare the cost or qualifications of coders and physicians.

The provider’s response

Once this insurer made its showing, the provider had to raise a triable issue. The opinion says the provider did not do so. It does not say that a competing expert is the only permissible response, or that the label “certified medical coder” makes every affidavit sufficient.

The practical reading is to examine the calculation actually supported by the affidavit and the evidence offered against it. A missing foundation, an inapplicable schedule or a disputed code must be assessed on the record; LVOV is not an automatic outcome for every billing dispute.

Original authority excerpt

The original post reproduced this passage from the opinion. It is judicial language, not a first-person account by Jason:

“the affidavit executed by defendant’s certified medical coder, submitted in support of defendant’s motion, established that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services in question (see Quality Comprehensive Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co., 65 Misc 3d 143, 2019 NY Slip Op 51734 ; see also Sama Physical Therapy, P.C. v American Tr. Ins. Co., 53 Misc 3d 129, 2016 NY Slip Op 51359 ).”

Connect to the Encyclopedia

Fee-schedule defense topic hub

• S.O.V.: a coder’s proof and conceded exceptions
• Okslen: responding to the insurer’s fee calculation
• First Aid: fee issues that remained for trial
• High Quality: the limits of an unlisted-item defense
• Therapeutic Physical Therapy: preservation is distinct from proof

For review of a particular bill or denial, contact the firm. The decision and commentary above concern the stated record; they do not determine a new claim.