Allstate Indemnity Company v. Gady Abramson, D.C., P.A.
A chiropractic provider billed aqua therapy under generic CPT code 97039 and sought PIP reimbursement at the rate for analogous listed modalities; Allstate instead limited payment to 80% of the workers' compensation maximum allowance because aqua therapy did not appear on the CY 2019 participating physicians fee schedule of Medicare Part B. The Third District reversed summary judgment for the provider, holding section 627.736(5)(a)(1)(f), Florida Statutes (2019), permits an insurer to resort to the workers' compensation schedule when a non-ambulatory, non-clinical-laboratory service is not listed on the participating physicians fee schedule.
Key facts
- Allstate Indemnity Company denied full PIP reimbursement to chiropractic provider Gady Abramson, D.C., P.A. for aqua therapy services billed under generic CPT code 97039, limiting payment to 80% of the workers' compensation maximum allowance because aqua therapy did not appear on the CY 2019 Medicare Part B participating physicians fee schedule.
- The trial court entered summary judgment for the provider; the Third District Court of Appeal reversed, holding that section 627.736(5)(a)(1)(f), Florida Statutes (2019), permits an insurer to resort to the workers' compensation schedule when a non-ambulatory, non-clinical-laboratory service is not listed on the participating physicians fee schedule.
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Why it matters
This is a significant PIP fee-schedule decision for insurers and providers litigating reimbursement of unlisted modalities billed under generic CPT codes such as 97039. The Third District rejects the 'analogous listed… — full analysis with a trial
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