No error in ordering repayment for services where reimbursement was initially denied because CPT code billed was not recognized by Medicare Part B or workers’ compensation fee schedules. The nature of the service controls, not the billed CPT code.

The 4th District Court of Appeal affirmed that the trial court correctly ruled that, when determining whether a CPT code is reimbursable under the Florida PIP Statute Section 627.736(5)(a)[1](f), the insurance company must look to the nature of the service as opposed to the individual CPT code in order to determine whether said service is reimbursable. 

In the lower court, the defendant moved for summary disposition, arguing that the low-level laser therapy that was billed under CPT code S8948 was compensable under the CPT code 97039. The nature of the dispute was due to the fact that S8948 is not reimbursable under the Medicare Fee Schedule, nor is it reimbursable under the Worker’s Compensation Fee Schedule. However, low level therapy itself is reimbursable under the Medicare Fee Schedule. The defendant argued that the plaintiff was required to reimburse the service under CPT code 97039. 

The trial court granted the plaintiff’s motion for summary disposition, finding that pursuant to Section 627.736(5) and Allstate Fire & Casualty Insurance Co. v. Jeffrey Tedder, M.D., P.A., a/a/o Jorge Perez, 111 So. 3d 960, the focus is on whether the services are reimbursable under the Medicare Part B or workers’ compensation fee schedules, not on whether the particular code is reimbursable. 

In its appeal, the defendant argued that S8948 lower laser therapy is not reimbursable under the Medicare Part B or workers’ compensation fee schedules and, therefore, the defendant was not entitled to reimbursement under section 627.736(5)(a)(1)(f). The court analyzed both section 627.736(5)(a)(1)(f) as well as the holding in United Auto. Ins. Co. v. Lauderhill Med. Ctr. LLC, No. 4D21-2308 (Fla. 4th DCA Nov. 9, 2022); United Auto. Ins. Co. v. Lauderhill Med. Ctr. LLC, No. 4D21-3336 (Fa. 4th DCA Nov. 9, 2022) and Perez, 111 So. 3d 960. In Lauderhill Medical, No. 4D21-2308, the 4th DCA made the following finding: “The language of section 627.736(5)(a)(2)(f) [now 627.736(5)(a)(1)(f)] is clear that the statute focuses on whether services, supplies, or care is ‘reimbursable under Medicare Part B’ and does not require that CPT codes be recognized by Medicare for reimbursement purposes.” The court used this analysis to conclude that in the instant case, “Focusing solely on the CPT code would be contrary to the dictates of the statute, where the relevant subsection does not even reference CPT Codes” and that laser therapy would be an unlisted modality. The court also found that while S8948 is recognized only by commercial payors, 97039 is a more general CPT code that also encompasses the therapy provided in the instant case. The plaintiff argued that section 627.736 does not require it to convert a specific, non-billable CPT code to a general reimbursable CPT code, but Perez held that insurers “would have to look beyond the CPT code to determine whether the services represented in the code are reimbursable.” Perez, 111 So. 3d at 964. 
 

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