Lauderhill Medical Center provided 'vibe therapy' to Robert White, an insured individual from a motor vehicle accident, billing under the non-specific CPT code 97039. United Auto Insurance Company, as the assignee, reimbursed the medical provider based on the workers' compensation fee schedule, paying 80% of the charges. The medical provider subsequently filed a complaint claiming underpayment of Personal Injury Protection (PIP) benefits, asserting that reimbursement should align with the higher Medicare fee schedule instead.
The trial court ruled in favor of the medical provider, determining that reimbursement under the workers' compensation schedule was improper and that the service fell under Medicare Part B. The insurer contested this decision, arguing that the service was not reimbursable under Medicare, thus limiting their payout to the workers' compensation schedule. The trial court referenced the case Allstate Fire & Casualty Insurance Co. v. Perez, affirming that CPT code 97039 is permissible under Medicare Part B, which lacks a set price, and concluded that the reimbursement should therefore be 80% of 200% of the allowable amount under the Medicare fee schedule.
The appellate court reviewed the matter de novo, including the statutory provisions of section 627.736, which governs reimbursement for medical services under PIP. The court upheld the trial court's judgment, affirming that the medical provider should be reimbursed according to the Medicare Part B fee schedule.
Services, supplies, or care not reimbursable under Medicare Part B may be reimbursed by the insurer at 80% of the maximum allowable under workers’ compensation, as per section 440.13 and its accompanying rules. If neither Medicare nor workers' compensation covers these services, the insurer is not obligated to provide reimbursement. Courts must interpret the PIP statute based on its clear wording, ensuring that every part of the statute is given effect and avoiding interpretations that render any part meaningless.
Section 627.736(5) specifies that the workers’ compensation schedule applies only if services are not reimbursable under Medicare Part B. In instances where a CPT code, such as 97039, lacks a set price but remains reimbursable under Medicare, the PIP statute permits a reasonable reimbursement up to 80% of 200% of the allowable amount, rather than utilizing the workers' compensation schedule. The trial court's summary judgment referenced the case of Perez, which found that, despite a CPT code being unrecognized at the time of service, the underlying medical services were still covered under Medicare Part B. The Perez court ruled that the insurer's application of the workers' compensation fee schedule was erroneous, affirming that the focus should be on whether the services are reimbursable under Medicare Part B, independent of the CPT code recognition. The interpretation aligns with the principle that the PIP statute should be liberally construed in favor of the insured, acknowledging potential confusion when providers use valid but unrecognized CPT codes.
The insurer must evaluate the services represented by the CPT code to determine their reimbursement eligibility under Medicare Part B, despite this complicating the reimbursement process under the PIP statute. Section 627.736(5)(a)(2)(f) does not mandate recognition of a CPT code by Medicare Part B if the services are otherwise covered. The insurer's attempt to differentiate this case from the precedent set in Perez is unpersuasive, as the additional language in the current statute does not alter the focus on Medicare Part B reimbursement. Neither version of the statute imposes a requirement for CPT codes to have a defined value under Medicare's fee schedule to qualify for reimbursement. The court cannot impose additional requirements not specified by the legislature, nor can it modify statutory language. Accepting the insurer's argument would render the provision regarding reimbursement percentages meaningless. The trial court's decision to apply Medicare Part B for payment under section 627.736(5) is upheld. The judgment is affirmed, with concurrence from Judges Conner and Kuntz. The ruling is not final until the resolution of any timely motion for rehearing.
