This letter provides a pre-hearing submission in a dispute over payment of medical bills from a car accident. It lists various medical procedures, the amounts billed and paid, and amounts still owed. It argues the medical necessity of tests like EMG/NCV based on exam findings and MRI results showing disc issues. Customary rates are provided from fee schedules and databases to support amounts claimed for procedures like pain fiber testing. The letter requests a total of $8,481.81 be awarded plus interest, fees, and costs.

1. March 18, 2015
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Forthright
285 Davidson Avenue, Suite 502
Somerset, NJ 08873
Attn: Casey Coordinator
Re: Superior Doctor Services a/s/o John Smith v. Insurance Co.
Forthright File No.: NJ0000000000000
Insurance Claim No.: 000000
Respondent File No.: 0000000000
Our File No.: 0000
D/A: 00/00/00
Dear Ms. Coordinator:
In regard to the above listed matter, please accept this letter in lieu of a more formal brief
as Claimant’s pre-hearing submission.
The following demand balance, as per fee schedule, is due upon the determination of pre-
certification compliance, medical necessity and UCR – similar service/crosswalk:
DOS CPT/Procedure Amount Billed Amount Paid Amount Owed
01/06/14 95912 - Pain fiber (Pre-cert.
penalty; UCR - 75% of
Optum Fair Health Data)
$2,700.00 $0.00 $1,319.00
01/06/14 95938 - Evoked Study (Pre-
cert. penalty; UCR - 75% of
Optum Fair Health Data)
$1,500.00 $0.00 $1,500.00
01/22/14 99214
Office Exam
(Medical necessity)
$160.00 $0.00 $125.71
01/22/14 95886 - 2 Units
EMG (Medical necessity;
Similar service 95861)
$400.00 $0.00 $327.48

2. Forthright No.: 0000000
March 18, 2015
Page 2 of5
01/22/14 95910 - NCV Testing (Med.
Nec.; Similar service 95903,
95904 & 95934)
$1,800.00 $0.00 $1,559.82
01/29/14 29881 RT
Right Knee Arthroscopy w/
meniscectomy (Paid-in-full)
$3,600.00 $3,531.15 $0.00
01/29/14 29877 59
Right Knee Synovectomy
(Unbundling; MMR)
$3,433.60 $0.00 $3,398.38
02/21/14 99214
Office Exam
(Insufficient documentation)
$160.00 $0.00 $125.71
03/19/14 99214
Office Exam
(Global service charge)
$160.00 $0.00 $125.71
Total Due: $8,481.81
Medical Necessity
The Supreme Court in the case of New Jersey Manufacturers Insurance Co. v. Hardy,
178 NJ 327 (2004), held the No Fault Act is given liberal construction in favor of its intended
remedial purpose of effecting broad protection for accident victims. Id at 392.
The necessity of medical treatment is a matter to be decided, in the first instance, by the
Claimant’s treating physicians, and an objectively reasonable belief in the utility of a treatment
or diagnostic method based on credible and reliable evidence of its medical value is enough to
qualify the expenses for PIP purposes. Thermographic Diagnostics v. Allstate, 125 NJ 491, 512
(1991).
N.J.A.C. 11:3-4.5(b)(1) & (2) provide, in part:
“(b) The personal injury protection medical expense benefits coverage shall provide for
reimbursement of the following diagnostic tests, which have been determined to have
value in the evaluation of injuries, the diagnosis and development of a treatment plan for
persons injured in a covered accident, when medically necessary and consistent with
clinically supported findings:
1. Needle electromyography (needle EMG) when used in the evaluation and diagnosis
of neuropathies and radicular syndrome where clinically supported findings reveal a
loss of sensation, numbness or tingling….
2. …Nerve conduction velocity (NCV)…are reimbursable when used to evaluate
neuropathies and/or signs of atrophy...”

3. Forthright No.: 0000000
March 18, 2015
Page 3 of5
In the matter at hand, Mr. John Smith injured his neck, back and right knee in a violent
motor vehicle accident on October 28, 2013, when he was struck as a pedestrian while crossing
the street. The force of the impact caused Mr. Smith to be thrown into the air and scrape along
the ground.
Immediately following the accident, Mr. Smith was transported via ambulance to
Hackensack University Medical Center, where his right knee was determined to be fractured.
On October 30, 2013, Mr. Smith came under the care of Dr. Grey for evaluation (see
Exhibit A). Dr. Grey reported low back with lower extremity pain and a positive straight leg
raise test. Dr. Grey recommended an orthopedic evaluation.
On October 31, 2013, Mr. Smith visited with Dr. House (see Exhibit B). Upon physical
exam, Dr. House noted increasing low back pain with numbness and burning sensations
radiating down the right leg. Dr. House recommended MRI testing.
On November 6, 2013 and November 14, 2013, Dr. Grey and Dr. House both reported
persistent, severe lumbar symptoms and recommended MRI testing (see Exhibit C).
On December 10, 2013, Mr. Smith underwent MRI testing of the lumbar spine which
revealed L5-S1 disc herniation as well as L4-L5 disc bulging (see Exhibit D).
On December 19, 2013, Dr. House reported worsening lumbar symptoms and
recommended possible pain management (see Exhibit E).
On January 8, 2014, due to the patient’s chronic pain with radicular symptoms and
positive MRI findings, Dr. Grey recommended EMG/NCV testing (see Exhibit F).
On January 22, 2014, Dr. Grey noted continued lumbar symptoms and recommended
they proceed with EMG/NCV testing (see Exhibit G).
That same day, EMG/NCV testing of the patient’s lower extremities revealed right L5
nerve root irritation (see Exhibit H).
On February 21, 2014, based on the EMG/NCV results, Dr. Grey recommended
continued chiropractic treatment in addition to beginning physical therapy (see Exhibit I).
On March 19, 2014, Dr. Grey reviewed the patient’s lumbar symptoms and
recommended continued chiropractic treatment and physical therapy (see Exhibit J).
Among the aforementioned reasons, EMG/NCV testing is necessary to confirm a
suspected diagnosis of the peripheral nervous system, localize damaged discs for pain
management considerations, and to properly advise the patient in the appropriate care path

4. Forthright No.: 0000000
March 18, 2015
Page 4 of5
standards.
Respondent denies payment based on the peer review of Dr. McDonald, claiming the
patient to only have “soft tissue injuries” and alleging no significant findings to support
EMG/NCV testing (see Exhibit B of Respondent’s March 17, 2014 submission). This is not
true.
In accordance with N.J.A.C. 11:3-4.5(b), EMG/NCV is necessary in the evaluation of
injuries when radicular syndrome or other neurological abnormalities are present.
At the time the EMG/NCV test was requested, Mr. Smith had radicular syndrome in his
back with numbness down the right leg (see Exhibit A, B & C). Dr. Grey and Dr. House’
findings, in conjunction with the MRI results revealing disc herniation (see Exhibit D)
evidence that the patient’s symptoms were not merely “soft tissue” and justified EMG/NCV
testing.
Therefore, in accordance with N.J.A.C. 11:3-4.10 and N.J.A.C. 11:3-4.5(b)(1) & (2), the
EMG/NCV testing was necessary to determine the next appropriate step in treatment and helped
the patient avoid pain management.
In regard to Respondent’s “lack of documentation” defense for the 2/21/14 Office Exam,
Claimant asserts the exam report was provided to Respondent with the HICFs and has been
produced again with Claimant’s brief. Under the principles of the entire controversy doctrine,
payment should be afforded (see Exhibit I).
In regard to Respondent’s “Global Service Charge” defense for the 3/19/14 Office Exam,
Claimant asserts Dr. Grey reviewed additional symptoms beyond that relating to the January 29,
2014 knee surgery, including those of the cervical and lumbar spine (see Exhibit J).
Usual Customary & Reasonable and/or Fee Schedule Similar Service
N.J.A.C. 11:3-29.4(e)(1) states in part:
“…the insurer’s limit of liability for any medical expense benefit for any service
or equipment not set forth in or not covered by the fee schedules shall be
reasonable amount considering the fee schedule amount for similar services or
equipment in the region where the service or equipment was provided.”
In regard to the pain fiber testing, DOBI Bulletin No. 10-30 states: “Department in Order
A10-113 concluded that the Ingenix MDR database can be used by insurers to determine the
reasonableness of fees that are not on the fee schedule”.
Claimant submits Optum Fair Health Data (formerly Ingenix) data (see Exhibit K) in

5. Forthright No.: 0000000
March 18, 2015
Page 5 of5
accordance with DOBI Bulletin10:28 and Order A10-113 for the following codes:
CPT code 95912 at $1,319.00 for the 75th percentile in 2014
CPT code 95938 at $2,020.00 for the 75th percentile in 2014*
*Claimant asserts Specialty Medical Services (SMS) under-billed CPT code 95938 for
$1,500.00 and so the total amount would be due. Claimant submits the corresponding pain fiber
testing to substantiate the claim (see Exhibit K).
In regard to the EMG/NCV testing, the January 22, 2014 report (see Exhibit H)
demonstrates that 1 unit of old code 95861 (EMG), 4 units of old code 95904 (Sensory NCV),
4 units of old code 95903 (Motor with F Wave) and 2 units of old code 95934 (H-Reflex) were
performed.
Under the 2013 fee schedule, reimbursement for the old codes would be as follows:
CPT code Description Units Fee schedule per unit Total
95903 Motor w/ F Wave 4 units $176.35 $705.40
95904 Sensory NCV 4 units $135.64 $542.56
95934 H-Reflex 2 units $155.93 $311.86
95861 2-Extremities 1 unit $327.48 $327.48
Similar Service Rate: $1,887.30
Based upon a UCR/similar fee schedule service analysis, Claimant has demonstrated that
$1,887.30 is a proper UCR for EMG/NCV testing performed.
As it is such, it is respectfully submitted that the amount of $8,481.81 with interest to be
calculated by Respondent, be awarded along with attorney’s fees and costs.
Very truly yours,
CORRADINO & PAPA, LLC.
By:___________________________________
C. KEVIN GRIM, JR.
CKG/na
cc: Jane Doe