V&B Magic Recovery Supply v. Geico Insurance Company (9/3/2010)
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The patient complained of cervical, thoracic, lumbar and left shoulder pain with weakness. After an examination was positive for decreased ranges of motion and tenderness in the cervical spine, lumbar spine and left shoulder, and positive Spurlings and Straight Leg Raise tests, the patient was referred for therapy. She was also given a prescription for medical supplies including a cervical pillow, a bed board, an egg crate mattress, an LSO, a hot/cold pack and a thermophore. The peer reviewer failed to provide sufficient evidence from medical literature to establish that these supplies lack medical necessity, thus the applicant was awarded benefits.

Rural/Metro Medical Services v. Allstate Insurance Company (8/11/2010)
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The maximum permissible charge for ambulance service is the local prevailing charge for such service in the geographic area where rendered. Respondent’s counsel is being disingenuous in contending that the Medicare fee schedule is evidence of the local prevailing charge for reimbursing ambulance in Western New York. The Department of Health and Human Services set the Medicare fee schedule with the aim of having ambulance providers share the cost burden of this particular social welfare program. Some studies have found that Medicare is designed to reimburse providers at less than their actual costs. Instead, in New York under the No-Fault regulations, an ambulance’s bill must simply reflect the local prevailing charge. Therefore, as a finding of fact, Applicant is awarded of $312.78 for full reimbursement for the ambulance service.


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