24 Fla. L. Weekly Supp. 191b
Online Reference: FLWSUPP 2402MIRAInsurance — Personal injury protection — Coverage — Medical expenses — Medical provider’s motion for summary judgment regarding relatedness, reasonableness and medical necessity of charge for electrodes is granted where provider met prima facie burden of proof, and opposing affidavits raise issue of improper billing and coding that was not preserved in affirmative defenses
FLORIDA INJURY KISSIMMEE, LLC a/a/o Theresa Miranda, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 13-018967 COCE 53. December 4, 2015. Robert W. Lee, Judge. Counsel: Matthew C. Barber, for Plaintiff. Rebecca Kay Cooperman, Kubicki Draper, for Defendant.
FINAL SUMMARY JUDGMENT FOR PLAINTIFF and
ORDER ON PLAINTIFF’S RENEWED MOTION FOR
SUMMARY JUDGMENT AND/OR MOTION
FOR SUMMARY DISPOSITION AS TO
RELATEDNESS, MEDICAL NECESSITY, AND
REASONABLENESS OF CHARGES,
AND THRESHOLD ISSUES
THIS CAUSE having come on to be heard on Plaintiff’s Motion for Summary Judgment/Disposition and Defendant’s Motion for Final Summary Judgment, the Court having been otherwise fully advised in the premises and by review of the File, Judicial Notice, Record, Arguments, Pleadings, Notices and Authorities, it is hereby,
ORDERED AND ADJUDGED:
1. Plaintiff’s Renewed Motion for Summary Judgment/Disposition is GRANTED.
2. Defendant’s Motion for Final Summary Judgment is DENIED.
3. The Court notes that the parties submitted a joint pre-trial stipulation, which is binding and shows the agreed upon disputed issues of fact and/or law. Defendant included over Plaintiff’s objections that A4556 was not payable when incident to a physician’s service, which is neither timely nor properly pled as an affirmative defense.
4. Plaintiff sought summary judgment/disposition as to reasonableness, relatedness and medical necessity for HCPCS code A4556 (electrodes/EMS pads) for date of service March 18, 2013. The Court finds that Plaintiff met its prima facie burden of proof based on the affidavits of Anicia Vicente, the billing director and records custodian, which includes the CMS-1500 form, as well as the affidavits of Dr. Joel Manion, D.C, Director of Clinic Operations. Specifically, the supplemental affidavit of Dr. Manion gives a detailed explanation of the medical necessity.
5. The burden shifted to Defendant to show a genuine issue of material fact to avoid summary judgment /disposition. In opposition, Defendant relied on the affidavit of Dr. Bradley Simon, D.C. and the affidavit of Denischa Torres-Lish. Both affidavits argue that A4556 was not properly billed and/or coded (i.e. electrodes were incident to service), which this Court finds is not preserved and is insufficient to avoid a summary judgment/disposition on reasonableness, relatedness and medical necessity. Again, there is no coverage/exclusion/unbundling/lack of notice defense pled. Plaintiff also argued by affidavit that these electrodes are not the disposable, one-use electrodes, which are normally incident to electrical muscle stimulation service, but rather a special, premium electrodes prescribed to the patient above the routine supplies or materials. The A4556 was billed one time, not every time electrical muscle stimulation was rendered.
6. The Court finds that there is not competent, substantial evidence which creates a genuine issue of material fact that disputes that A4556 (electrodes/EMS pads) was reasonable, related to the auto accident and medically necessary. The Court finds that $15 is reasonable for A4556 (electrodes/EMS pads), and thus covered under the No-Fault Law (2013).
7. IT IS HEREBY ORDERED AND ADJUDGED that Plaintiff, FLORIDA INJURY KISSIMMEE a/a/o Theresa Miranda shall recover from Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, the sum of $12.00 representing PIP benefits at 80% that Defendant did not pay, plus pre-judgment interest in the amount of $1.49 (daily rate as decimal of .000130137 for 957 days). Defendant shall also pay post judgment interest at the applicable rate of interest until satisfied. Therefore, the total judgment is $13.49, for which let execution issue. The Court specifically reserves jurisdiction to determine any motions for attorney’s fees and costs.
