“Pilates” Provider Not Eligible for Reimbursement Under No Fault
Applicant_1 and New York Central Mutual Fire Ins. Co.
AAA Case No. 412009033424, Arbitrator Thomas J. McCorry
Amount in Dispute: $1,071.00
In this arbitration, the Buffalo Neurosurgery Group wrote a “prescription” to the injured party for “Pilates.” To be clear, we are talking about the “physical fitness system” developed in the early 20th century by German gymnast Joseph Pilates.
The provider, an employee of The Fitness Institute, billed for his services with a physical therapy CPT code, though conceded that he was not a licensed physical therapist. The provider claimed to have done this on account of there being no specific billing code for “Pilates” in the no fault schedule.
The arbitrator found that it was inappropriate for the provider to bill under a physical therapy code when it was not a licensed physical therapist. The arbitrator upheld the insurer’s denial that the provider was not eligible for reimbursement per Section 5102(a)(1) of the insurance law.
It remains to be seen however, whether a licensed physical therapist would have a reimbursable claim for “Pilates” treatment, as this denial was upheld only on the ground that the provider was not a recognized “provider of health care services.”
Roy Mura
Bethany Mazur
Scott Mancuso
The arbitrator found that it was inappropriate for the provider to bill under a physical therapy code when it was not a licensed physical therapist.
How does the arbitrator feel about acupuncturists?