Thanks to Robert N. Feltoon, who took the lead on the MSJ on behalf of all insurers, for bringing it to my attention. Skip Short was co-counsel.
Brentwood Pain & Rehabilitation Services., et. al. v. Allstate, et. al., 2007 WL 2687416(S.D.N.Y, Sept. 14 2007)
The decision is 13 pages long, I’m going to try to post the relevant parts without making this post enormous.
In this case, the issue presented is whether MRIs are covered by regulations that limit the fees that can be charged under the New York no-fault auto insurance law when multiple body parts are imaged in one session. The New York State Workers’ Compensation Board (“ WCB” ), the New York State Department of Insurance (“ DOI” ), and the defendants in this case (numerous insurance companies (“ Insurers” )) would apply the same fee limitations to MRIs as are applied to x-rays under the WCB schedule of medical fees, and adopted by DOI under New York’s no-fault statute. Plaintiffs Brentwood Pain & Rehabilitation Services, P.C., Hempstead Pain & Medical Services, P.C., and Signature Health Center, LLC (together, “ Providers” ) contend that limiting the reimbursement of MRI in this way is improper and violates the terms of the insurance contracts between the parties.
Providers move to certify this case as a class action, with themselves as class representatives for all New York MRI service providers similarly situated. Insurers oppose class certification and move for summary judgment, contending that Providers’ claim must be dismissed in light of interpretations of the relevant regulations by DOI and WCB. In response to Insurers’ motion, Providers cross-moved for summary judgment in their favor.
1. WCB Fee Schedule
Chapter five of the WCB Fee Schedule is titled “ radiology” and is devoted to all radiological procedures. The chapter includes the Ground Rules and fee codes (“ CPT codes” ) for all radiological services. (WCB Fee Schedule 1). The introduction to chapter five states that the definitions and rules contained therein “ pertain[ ] to radiology (including nuclear medicine and diagnostic ultrasound).” (Id.).
a. The Ground Rules
The Ground Rules are titled “ Radiology Ground Rules.” (Id.). Ground Rule 1 states that “ [c]onsultations and referrals for diagnostic and therapeutic radiology are to be done only by specialists.” (Id.).
Ground Rule 3 is titled “ Multiple Diagnostic X-Ray Procedures.” (Id.). It does not explicitly refer to MRI. (See id.). This Rule provides in pertinent part:
The following adjustments apply:
(a) For two contiguous parts, the charge shall be the greater fee plus 50 percent of the lesser fee.
(b) For two remote parts, the charge shall be the greater fee plus 75 percent of the lesser fee. Bilateral procedures are considered remote parts
(c) For three or more parts, whether contiguous or remote, the charge shall be the greatest fee plus 75 percent of the total of the lesser fees.
….
(f) X-rays of different areas taken on different but proximate dates and related to the injury or problem necessitating the first x-ray studies, and which could have reasonably been performed at one time, shall be subject to rules … above.(Id. at 1-2). In essence, these rules provide for discounting of the relative values prescribed by the WCB Fee Schedule when multiple body parts are, or could have been, imaged in one session. Additionally, Ground Rule 5 is applicable to “ multiple services other than diagnostic radiology,” and states that “ [w]hen multiple or bilateral procedures or services are provided at the same session, payment is for the procedure with the highest allowance plus half of the lesser procedures up to a total maximum allowance of twice the highest fee.” (Id.).
For the above reasons I conclude that DOI’s interpretation is not irrational or unreasonable, and is entitled to deference. I conclude that the interpretation of Ground Rule 3 as limiting charges for MRI should be upheld. Consequently, plaintiffs’ claim must be dismissed as a matter of law, and their motion for class certification therefore must be denied as moot.
I’ll fill in the gap between the initial discussion and the holding later.