111 So. 3d 960
Fla. Dist. Ct. App.2013Background
- Allstate appeals a county court summary judgment in Dr. Tedder's favor regarding Perez's PIP benefits.
- Perez assigned his PIP benefits to Dr. Tedder after receiving medical services for an automobile accident.
- Dr. Tedder billed CPT code 99245; Allstate paid 80% of the workers’ compensation fee schedule amount instead of Medicare Part B 200% schedule.
- CMS announced CPT 99245 would no longer be recognized for Medicare Part B payment effective January 1, 2010, though the services remained covered if reasonable and necessary.
- The county court held the services were reimbursable under Medicare Part B for 2010, so the workers’ comp schedule was inappropriate.
- The court certified the judgment as a matter of great public importance and remanded to interpret section 627.736(5)(a)(2) relating to CPT codes and fee schedules.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether services reimbursable under Part B fall under 627.736(5)(a)(2)(f). | Tedder: CPT 99245 services are Part B reimbursable despite code changes. | Allstate: CPT 99245 not recognized by Part B 2010 schedule; apply workers’ comp. | Yes; services are reimbursable under Part B, not confined to recognized CPT codes. |
Key Cases Cited
- Kingsway Amigo Ins. Co. v. Ocean Health, Inc., 63 So.3d 63 (Fla. 4th DCA 2011) (two payment methods under statute 627.736(5))
- Holly v. Auld, 450 So.2d 217 (Fla. 1984) (plain language of statute must be given effect)
- Peace River/Manasota Reg’l Water Supply Auth. v. IMC Phosphates Co., 18 So.3d 1079 (Fla. 2d DCA 2009) (court cannot add words to statutes)
- Overstreet v. State, 629 So.2d 125 (Fla. 1993) (statutory interpretation when plain language governs)
- State Farm, Mut. Auto. Ins. Co. v. Pressley, 28 So.3d 105 (Fla. 1st DCA 2010) (PIP liberal construction in insured's favor)