Harbor Chiropractic, P.C

American Arbitration Association New York No-Fault Arbitration Tribunal In the Matter of the Arbitration between: Harbor Chiropractic, P.C. AAA Case No. 17-18-1084-8145 (Applicant) Applicant's File No. 113141 - and - Insurer's Claim File No. 0397235870 NAIC No. 19232 Allstate Insurance Company (Respondent) ARBITRATION AWARD I, James Hogan, the undersigned arbitrator, designated by the American Arbitration Association pursuant to the Rules for New York State No-Fault Arbitration, adopted pursuant to regulations promulgated by the Superintendent of Insurance, having been duly sworn, and having heard the proofs and allegations of the parties make the following AWARD: Injured Person(s) hereinafter referred to as: EIP 1. Hearing(s) held on 04/18/2019, 06/19/2019 Declared closed by the arbitrator on 04/18/2019 Michael Spector from The Odierno Law Firm P.C. participated in person for the Applicant Allison Lindsey from Law Offices Of Karen L Lawrence participated in person for the Respondent 2. The amount claimed in the Arbitration Request, $ 4,241.52, was AMENDED and permitted by the arbitrator at the oral hearing. At the hearing, the Applicant amended the amount in controversy to $2,778.45 to be in accordance with the Chiropractic Fee Schedule for both the CMT and physical medicine services provided on the 18 DOS, but also to be in accordance with the fee schedule for the range of motion testing and manual muscle testing. Stipulations WERE NOT made by the parties regarding the issues to be determined. 3. Summary of Issues in Dispute The EIP, a 27 year old female, was injured in a collision on 12/30/15. This claim is for services provided to the EIP as follows: Page 1/16 3. CMT, hot/cold packs and electrostimulation, billed at $63.74 for DOS 9/13, 9/21, 9/26, 9/29, 10/5, 10/11, 10/12, 10/19, 10/24, 10/31, 11/2, 11/8, 11/9, 11/16, 11/30, 12/7, 12/9 and 12/14/16. (18 DOS) Range of motion testing billed under CPT code 95851 at $457.10 for DOS 9/29, 11/2, and 11/16/16. Manual muscle testing billed under CPT code 95831 at $523.20 for DOS 11/9/16 and12/14/16. Manual muscle testing billed under CPT code 95831 at $261.60 for DOS 11/30/16. Manual muscle testing billed under CPT code 95831 at $436.00 for DOS 12/7/16. On 4/4/16, Respondent issued a global NF-10 denying all future chiropractic and massage therapy benefits based upon an IME done on 3/19/16 by Michael Berke, DC. The effective date of the denial was 4/11/16. On 1/6/17, Respondent issued an NF-10 re DOS 12/14/16 and billing in amount of $523.20. Respondent paid $86.01 leaving in amount in dispute of $437.19. As per the EOB, the Applicant billed a total of 12 units for manual muscle testing under CPT code 95831. Respondent paid $86.01 same the payment was adjusted to reflect allowance for total body evaluation including the hands under CPT code 95834. (14.88 RVUs x $5.78 = $86.01) The remainder of the Applicant's billing was denied based upon the negative IME. 4. Findings, Conclusions, and Basis Therefor This decision is based upon my review of the electronic file maintained by the American Arbitration Association, and the arguments of the parties set forth in the hearing. SUMMARY OF THE CASE: The EIP, a 27 year old female, was injured in a collision on 12/30/15. This claim is for services provided to the EIP as follows: CMT, hot/cold packs and electrostimulation, billed at $63.74 for DOS 9/13, 9/21, 9/26, 9/29, 10/5, 10/11, 10/12, 10/19, 10/24, 10/31, 11/2, 11/8, 11/9, 11/16, 11/30, 12/7, 12/9 and 12/14/16. (18 DOS) Page 2/16 4. Range of motion testing billed under CPT code 95851 at $457.10 for DOS 9/29, 11/2, and 11/16/16. Manual muscle testing billed under CPT code 95831 at $523.20 for DOS 11/9/16 and12/14/16. Manual muscle testing billed under CPT code 95831 at $261.60 for DOS 11/30/16. Manual muscle testing billed under CPT code 95831 at $436.00 for DOS 12/7/16. On 4/4/16, Respondent issued a global NF-10 denying all future chiropractic and massage therapy benefits based upon an IME done on 3/19/16 by Michael Berke, DC. The effective date of the denial was 4/11/16. On 1/6/17, Respondent issued an NF-10 re DOS 12/14/16 and billing in amount of $523.20. Respondent paid $86.01 leaving in amount in dispute of $437.19. As per the EOB, the Applicant billed a total of 12 units for manual muscle testing under CPT code 95831. Respondent paid $86.01 same the payment was adjusted to reflect allowance for total body evaluation including the hands under CPT code 95834. (14.88 RVUs x $5.78 = $86.01) The remainder of the Applicant's billing was denied based upon the negative IME. At the hearing, the Applicant amended the amount in controversy to $2,778.45 to be in accordance with the Chiropractic Fee Schedule for both the CMT and physical medicine services provided on the 18 DOS, but also to be in accordance with the fee schedule for the range of motion testing and manual muscle testing. Applicant's submission: The Applicant has provided a copy of its billing. (see above) The EIP had an initial evaluation at the Applicant on 1/11/16. She reported being involved in an MVA on 12/30/15. She developed pain in the head, neck, right shoulder, left shoulder, mid back and low back. She had an evaluation to Southside Hospital. X-rays were taken of the lower back. She presented to the Applicant with complaints of headache, pain in the neck, and mid back pain. She was also experiencing pain in the lumbar spine area. She rated her headache pain at 7/10; neck pain and 9/10; mid back pain at 5/10; low back pain is 5/10. After comprehensive examination, which included provocative orthopedic testing, the Diagnosis was: 1) subluxation of unspecified cervical vertebra; 2) subluxation of unspecified thoracic vertebra: 3) subluxation of unspecified lumbar vertebra; 4) muscle Page 3/16 4. spasm; 5) myalgias; 6) tension-type headaches; 7) subluxation complex (vertebral) of sacral region; 8) subluxation complex (vertebral) of pelvic region. The Plan call for the initiation of therapy at the rate of 4 times per week for 4 weeks followed by a re-valuation. On 2/15/16, the EIP had a re-evaluation at the Applicant. She still complained of headache, pain in the area of the cervical spine, mid back pain and lumbar spine pain. The palpation examination found spasm in the neck, mid back and low back. The EIP had a normal gait. Evaluation for joint mobility found a moderate loss of joint function at occiput-C7, T1-T 12, L1-L5 and the left ilium-sacrum was elicited. The palpation examination revealed moderate pain at occiput-C7, T1-T 12, L1-L5 and the ilium-sacrum, bilaterally. Spasticity was noted in the sub occipital muscles, cervical paraspinal muscles, upper thoracic muscles, mid thoracic muscles, lower thoracic muscles, lumbar paraspinal muscles and gluteal muscles, bilaterally. DTRs in the triceps, biceps, brachioradialis, Achilles and patellar were each 2+/5, bilaterally. A number of provocative orthopedic tests were either positive, or positive, bilaterally. The dermatome evaluation utilizing a pinwheel revealed all dermatomes tested were normal with the exception of C5 hypoesthesia and bilateral L5 hypoesthesia. Muscle testing in the bilateral upper extremities was graded at 5/5. The range of motion for the cervical spine was indicated as decreased in flexion, extension, bilateral lateral flexion and bilateral rotation, but not quantified. The range of motion for the lumbar spine was indicated as decreased in the pelvic sacral angle, flexion, extension, and bilateral lateral flexion, but not quantified. After the examination the Diagnosis was: 1) subluxation of unspecified cervical vertebra; 2) subluxation of unspecified thoracic vertebra: 3) subluxation of unspecified lumbar vertebra; 4) muscle spasm; 5) myalgias; Page 4/16 4. 6) tension-type headaches; 7) subluxation complex (vertebral) of sacral region; 8) subluxation complex (vertebral) of pelvic region. 9) postural kyphosis, cervicothoracic region; 10) acquired deformity of neck. 11) Disorder of ligament, vertebrae. The Assessment indicates that the patient's condition has reached an intermediate stage. Adjustment of vertebra revealed an indication of a modest degree of movement and joint dysfunction reduction at occiput-C7, T1-T 12, L1-L5 and the left ilium-sacrum. This report reflects the findings of x-rays taken on 1/25/16. It is noted that the patient was referred to massage therapy. On 3/21/16, the EIP had a re-examination at the Applicant. She presented to the office stating that she was feeling a headache. In addition, she had pain in the neck which was described as constant, moderate and restricts the movement as well as radiating to the bilateral shoulders. She has been having mid back pain which was described as constant and moderate spasm as well as deep and achy pain. She also had pain in the lower back described this constant moderate which restricted her movements; it was a stabbing pain that radiated to the buttocks, left posterior thigh and right posterior thigh.

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