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February 19, 2015
Via Electronic Upload
Forthright
285 Davidson Avenue, Suite 502
Somerset, NJ 08873
RE: Generic Orthopaedic Medicine Center A/S/O Jane Doe V. GEICO Insurance
Company
Ref. No.: NJ1501001234567
Claim #: 123456789
D/L: 04/10/2012
Dear Parties:
As you are aware, this office represents the interests of Generic Orthopaedic Medicine Center in
connection with unpaid medical bills for services rendered to Jane Doe. Kindly accept the following is
Claimant’s supplemental arbitration submission.
First, Claimant concedes to the payment for date of service February 14, 2013 in the amount of
$153.17. Kindly see the updated Rule 16 breakdown indicated below:
Provider Name: Generic Orthopaedic Medicine Center
DOS CPT Billed FS Paid Owed Issue
2/14/2013 99244 $ 400.00 $ 200.30 $ 153.17 $ 47.13 Down-coding to CPT 99243
6/16/2013 64721 $ 2,500.00 $ 2,074.12 $ - $ 2,074.12 Medical Necessity; Causation; and
Failure to Appeal6/16/2013 64721xAS $ 1,250.00 $ 352.60 $ - $ 352.60
TOTAL $ 2,473.85
TOTAL MEDICAL BENEFITS CLAIMED: $2,473.85 plus interest
In this matter, the patient was involved in a motor vehicle accident on April 10, 2011, as a result
of which he sustained injuries to the neck, low back, and bilateral upper extremities. The patient was
initially seen by Dr. John Smith, two days following the accident reporting neck and low back pain with
radicular symptoms. He was also seen by an acupuncturist on July 14, 2012 with similar symptoms. On
November 30, 2012, he presented for an initial pain management evaluation at Generic Pain Control
Center, where he reported neck pain radiating into both upper extremities with numbness, tingling, and
weakness, as well as low back pain radiating into both lower extremities with numbness, tingling, and
weakness. At this time, the patient was recommended to undergo EMG/NCV studies of the upper and
lower extremities in order to diagnose the nerve root compression and other peripheral and central

Your Company, LLC
Re: Generic Orthopaedic Medicine Center A/S/O Jane Doe V. GEICO Insurance Company
P a g e | 2
causes of the patient’s neuropathy. The patient continued pain management treatment through August
17, 2012. (See the medical records attached to Claimant’s initial submission as Exhibits B-D).
On September 4, 2012, the patient underwent an electrodiagnostic study of the upper and lower
extremities. The study revealed evidence of a moderate bilateral sensorimotor median nerve neuropathy
at the wrist, consistent with a clinical diagnosis of carpal tunnel syndrome, worse on the left. The patient
was also diagnosed with left C4-C5 radiculopathy. (See the electrodiagnostic study attached hereto as
Exhibit E).
On February 14, 2013, the patient presented for an initial orthopedic evaluation with Dr. Bruce
Wayne. At the time of this evaluation, the patient reported experiencing continued complaints of pain in
the neck, back, and bilateral upper extremities. He specifically noted numbness in his fingers on the left
worse than right, difficulty lifting objects, and dropping objects. It was additionally noted that his
bilateral hand pain was worsening. Regarding his past medical history, it was noted that he was not
experiencing or treating for a wrist related condition prior to the accident of record, and was not
involved in a subsequent injury. Examination of both wrists revealed positive Tinel’s and Phalen’s signs
of the carpal tunnel region on both sides, more on the left than the right. Dr. Wayne reviewed the
imaging studies, as well as the electrodiagnostic study, and diagnosed the patient with neck and back
strain, cervical and lumbar spine, disc herniation, and traumatic bilateral carpal tunnel syndrome. At this
time, the patient was recommended to continue conservative treatment for the neck and back. Carpal
tunnel release surgery was later recommended. (See the medical evaluations of Dr. Wayne attached to
Claimant’s initial June 27, 2014 submission as Exhibit F).
On June 16, 2013, the patient underwent left carpal tunnel release. (See the operative report
attached to Claimant’s initial submission as Exhibit G).
The patient returned for a postoperative follow up evaluation on July 26, 2013. At this time, it
was noted that the patient was doing better with less pain and improved function. (Exhibit F).
Precertification for the June 16, 2013 date of service was successfully submitted on February 17,
2013. (See the precertification request attached to Claimant’s initial arbitration submission as Exhibit
H). Letters of appeal for precertification denial were successfully submitted on February 29, 2013, and
August 2, 2013. A letter of appeal for nonpayment of the February 14, 2013 and June 16, 2013 dates of
service was successfully submitted on January 24, 2014. (See the letters of appeal attached to Claimant’s
initial arbitration submission as Exhibit I).
LEGAL ARGUMENT
CPT Code 99244 was Improperly Down-Coded.
Pursuant to the Respondent’s submission, it argues that CPT code 99244 for date of service
February 14, 2013 was down-coded to CPT code 99243. It is the Claimant’s position, however, that the

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reduction of the originally billed code was improper. CPT code 99244 is defined as an office
consultation for a new or established patient, which requires the following three components:
 A comprehensive history;
 A comprehensive examination; and
 Medical decision making of moderate complexity
A comprehensive history includes the patient’s chief complaint; extended history of present illness;
review of systems that is directly related to the problem(s) identified in the history of the present illness,
plus a review of additional body systems; as well as complete past, family, and social history. A
comprehensive examination includes a general multisystem examination or a complete examination of a
single organ system. Lastly, the complexity of medical decision-making is based on the following:
 The number of possible diagnoses and/or the number of management options that
must be considered
 The amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed, and analyzed
 The risk of significant complications, morbidity, and/or mortality, as well as
comorbidities associated with the patient’s presenting problem(s), the diagnostic
procedure(s), and/or the possible management options.
If the evaluation results in multiple diagnoses were management options, a moderate amount and/or
complexity of data to be reviewed, with moderate complications and/or morbidity or mortality, the type
of decision-making is considered that of moderate complexity. (See the 2012 AMA CPT Manual
attached to Claimant’s initial submission as Exhibit J).
It is the Claimant’s position that each of these components was substantially met at the time of
the February 14, 2013 evaluation. Dr. Wayne performed a comprehensive of history, which included the
patient’s history of present illness, past medical history, family history, medications, past surgical
history, social history, and allergies. A comprehensive examination was then performed, which reviewed
the patient’s ambulation, skin, cervical spine, bilateral upper extremities, and low back. A moderate
complexity of medical records was then reviewed, including the patient’s cervical MRI, lumbar MRI,
and EMG/NCV study of the upper extremities. The patient was then provided with a total of five
diagnoses and/or management options, including and back strain, cervical and lumbar spine, disc
herniation, bilateral carpal tunnel syndrome, continued conservative treatment with exercise and
possible chiropractic treatment, and carpal tunnel release surgery. Additionally, Claimant would like to
point out that Respondent does not provide any type of code certification review in support of the down-
coding to CPT code 99243. As the February 14, 2013 evaluation substantially met all components
required to support the billing of CPT code 99244, it is the Claimant’s position that an additional $47.13
remains due and owing.

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Medical Necessity/Causality
Pursuant to Respondent’s submission it argues that the services rendered were not medically
necessary or causally related. It is Claimant’s position the treatment rendered was, in fact, causally
related and medically necessary, and that payment is due and owing.
Where medical necessity is disputed, the Claimant bears the burden to prove by a preponderance
of the evidence that the services for which PIP payment is sought were reasonable, medically necessary
and causally related to an automobile accident. See Miltner v. Safeco Ins. Co. of Am., 175 N.J. Super.
156 (Law Div. 1980). 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 the credible and reliable evidence of its medical value is enough to qualify
the expense for PIP purposes. See Thermographic Diagnostics, Inc. v. Allstate Ins. Co., 125 N.J. 491
(1991). In a conflict of opinion between medical experts, generally greater weight is given to the
opinion of the treating physician. See Abelit v. Gen. Motors Corp., 46 N.J. Super. 475, 480 (citing
Bialko v. H. Baker Milk Co., 38 N.J. Super. 169, 171 (App. Div. 1957)). While the treating provider’s
opinion is not entitled to a conclusive presumption of accuracy, it is accorded an appropriate measure of
deference. See Black & Decker Disability Plan v. Nord, 123 S.Ct. 1965 (2003).
Medical expenses have been considered necessary even if the services only provide temporary
relief from symptoms and will neither cure nor repair a medical condition or problem. Miskofsky v.
Ohio Casualty Ins. Co., 203 N.J. Super. 400 (Law Div. 1984). While the fact that a treatment is only
intended to provide relief from symptoms is not alone a reason to deny benefits, such treatment must
still be reasonable and necessary. Palliative care is compensable under PIP when it is medically
reasonable and necessary. See Elkins v. New Jersey Manufacturers Ins. Co., 244 N.J. Super. 695 (App.
Div. 1990). “Medical necessity”, as defined by N.J.A.C. 11:4-2, is medical treatment or diagnostic
testing which is consistent with the clinically supported symptoms, diagnosis or indications of the
injured person. “Clinically supported” is further defined as a personal examination in which the
physician makes an assessment subjective testing, complaints, observations, objective findings,
neurologic indications and physical tests. Nowhere, do the regulations require that the physician make
an objective finding in order to administer a diagnostic test. Rather, the regulations clearly contemplate
that such findings (or the lack thereof), are only a portion of a physician’s assessment of the patient in
their decision making process. In fact, the regulations require the recording and documentation of
positive and negative findings and conclusions on the patient’s medical records.
New Jersey Courts have consistently and emphatically reinforced the proposition that claims for
medical expenses benefits payments are to be processed liberally and promptly. As set forth in
Gambino v. Royal Globe Ins. Co., 86 N.J. Super. 100, 107 (App. Div. 1981);
In interpreting the statute to give full effect to the legislative intent, then the statutory language must
read, whenever possible to promote prompt payment to all insured persons for all of their losses.

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The New Jersey Supreme Court held in Amiano v. Ohio Casualty Ins. Co., 85 N.J. 85, 90 (1980):
Moreover, the Act itself requires us to construe its provisions liberally in order to effect the
legislative purpose to the fullest extent possible. N.J.S.A. 39:6A-16. The No Fault Act is social
legislation intended to provide insureds with the prompt payment of medical bills, lost wages and
other such expenses without making them await the outcome of protracted litigation. Mandated
as a social necessity, PIP coverage should be given the broadest application consistent with the
statutory language.
In accordance with the broad and liberal construction of PIP, the Courts have also extended the
principal to expand the definition of acceptable treatment. As the Court noted, “...reasonable and
necessary medical treatment appropriately may be rendered to preserve life or simply to relieve the
patient from physical pain.” See Elkins v. New Jersey Manufacturers Ins. Co., 244 N.J. Super. 695, 700
(App. Div. 1990). Accordingly, a PIP carrier has an encompassing duty to provide payment in full for
treatment that results in the alleviation of pain, without regard to the curative aspect of treatment. See,
Elkins, supra at 700; Miskofsky v. Ohio Casualty Ins. Co., 203 N.J. Super. 400, 413-414 (Law Div.
1984); Cavagnaro v. Hanover Ins. Co., Inc., 236 N.J. Super. 287, 291-292 (Law Div. 1989).
In this matter, the reports and records submitted record in detail the patient’s subject complaints
as well as the results of examination and testing which provide objective corroboration. The patient
presented for an initial evaluation with Dr. John Smith nearly 2 days following the motor vehicle
accident with complaints of neck pain radiating into both upper extremities. At the time of the
November 30, 2011 evaluation, the patient reported continued neck pain radiating into both upper
extremities with numbness, tingling, and weakness. The patient was recommended to undergo
EMG/NCV studies of both upper and lower extremities, however, there were issues with the insurance
company, and an EMG/NCV study was not performed until September 4, 2012. Until that time, the
patient’s bilateral upper extremity pain, numbness, tingling, weakness was originally associated with
radicular syndrome. It wasn’t until the EMG/NCV study performed on September 4, 2012, that bilateral
carpal tunnel syndrome, worse on the left, was diagnosed. A specific examination of both wrists was not
performed until February 14, 2013 by Dr. Bruce Wayne. Examination at that time revealed positive
bilateral Tinel’s and Phalen’s signs, worse on the left than the right. Based on the patient’s
electrodiagnostic study, as well as positive findings on examination, Dr. Wayne diagnosed traumatic
bilateral carpal tunnel syndrome related to the motor vehicle accident of March 20, 2011. As such,
carpal tunnel release surgery was recommended for the left wrist. Based on the foregoing and the extent
of the patient’s injury, it was in Dr. Wayne’s professional opinion within a reasonable degree of medical
certainty that the carpal tunnel surgery was appropriate, necessary and reasonable given the injuries that
the patient sustained in the April 10, 2011 motor vehicle accident.
Please be advised that the Respondent relies on a physician advisor review rendered by Dr. Ray
Charles on February 28, 2013. After review of this report, it is important to note that Dr. Charles bases

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his decision on the fact that a prior independent medical examination performed on June 2, 2012, did not
make any mention of carpal tunnel syndrome being present. Claimant would like to point out that the
IME report that was reviewed was rendered prior to the electrodiagnostic study performed on September
4, 2012, and therefore a diagnosis of same was not yet rendered. As noted previously, the patient’s upper
extremity pain, numbness, tingling, and weakness was originally related to the patient’s diagnosis of
cervical radiculopathy. Additionally, Respondent does not provide a copy of the June 2, 2012 IME
report, and therefore, Dr. Charles’ basis for his determination lacks standing.
Lastly, Claimant relies on an IME rendered on December 4, 2013 by Dr. Clark Kent, which
specifically states that the patient’s diagnosis of carpal tunnel syndrome was in fact causally related to
the accident of record. (See the IME report attached to Claimant’s supplemental submission as Exhibit
K).
Appeals
Lastly, pursuant to the Respondent’s submission, it argues that Claimant lacks standing to pursue
arbitration, as a letter of appeal was not submitted within 10 business days of the precertification denial.
Additionally, the Respondent argues that an appeal report was not rendered as a precertification appeal
was never submitted. It is the Claimant’s position, however, that the appeals process was properly
followed, as a letter of appeal was in fact submitted on January 29, 2013, one day following the
precertification denial. (Exhibit I of Claimant’s initial June 27, 2014 submission). Furthermore, the
letter of appeal specifically states:
“The denial does not contain a medical basis. This appeal was submitted to preserve the
assignment of benefits. Please provide the medical basis for denying the patient’s treatment, so
the patient and I may make an informed decision. I will continue to treat the patient in
accordance with the treatment plan. Merely stating that the treatment is denied and/or that
document is lacking does not provide a medical basis for denying this patient’s treatment. Please
provide a copy of the peer review report. If the insurance carrier requests further documentation,
please state in writing specifically which documentation you request, so I may make an informed
decision whether to perform further examinations and/or submit further documentation to
support the treatment.”
Claimant never received an appeal response, or copy of the report denying treatment. As such, it is the
Claimant’s position that the appeals process was not only properly followed by Claimant, but the
Respondent did not follow the regulations indicated in N.J.A.C. 11:3-4.7 (e):
6. The insurer shall notify the injured person or his or her designee and the treating medical
provider whether it will reimburse for further treatment, diagnostic tests or durable
medical equipment as promptly as possible, but in no case later than three business days
after the examination. If the examining provider prepares a written report concerning the

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examination, the injured person or his or her designee shall be entitled to a copy upon
request.
As such, Claimant does in fact have standing to arbitrate for nonpayment of dates of service February
14, 2013 and June 16, 2013.
Itemization of documents relied upon to support position(s) identified above:
1. Demand for Arbitration;
2. Medical Bills/Itemization;
3. Claimant’s initial and supplemental arbitration submissions;
4. Assignment of Benefits; and
5. Attorney Fee Certification
Very truly yours,
_________________, Esq.

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