Bronx Acupuncture Therapy, P.C., v. Hereford Ins. Co., Slip Copy, 2017 WL 416732 (Table), 2017 N.Y. Slip Op. 50101(U)
Provider billed for 97039 and 99199 of the workers’ compensation fee schedules. Plaintiff submitted three claim forms to defendant which included charges for moxibustion, under code 97039, which is described as “Unlisted modality (specify type and time if there was constant attendance)” and for one session of acupressure, under code 99199, which is described as “Unlisted special service, procedure or report.” The workers’ compensation have assigned them a “By Report” designation, which requires provider submit additional documentation to the insurer to determine the amount of reimbursement. Plaintiff did not submit such documentation or proof with its claim. Insurer did not, request any additional verification which was fatal to its case.
The Court said:
As defendant failed to demonstrate upon its motion that it had requested any additional verification from plaintiff seeking the information it required in order to review plaintiff’s claims for services billed under codes 97039 and 99199 of the workers’ compensation fee schedules, defendant was not entitled to summary judgment dismissing so much of the complaint as sought *2 to recover for services rendered under those codes (see Gaba Med., P.C. v Progressive Specialty Ins. Co., 36 Misc 3d 139[A], 2012 NY Slip Op 51448 [U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]; see generally Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]).