CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration bet

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1 CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z v. INS. CO. CLAIMS NO.: GHJB FIRST TRENTON INDEMNITY DRP NAME: Barry E. Moscowitz (Respondent) NATURE OF DISPUTE: Usual, Customary, and Reasonable; Application of and Adherence to Fee Schedule; and Medical Necessity AWARD OF DISPUTE RESOLUTION PROFESSIONAL I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP), designated by the American Arbitration Association under the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New Jersey Automobile Insurance Cost Reduction Act as governed by N.J.S.A. 39:6A-5, et. seq., and, I have been duly sworn and have considered such proofs and allegations as were submitted by the Parties. The Award is DETERMINED as follows: Injured Person(s) hereinafter referred to as: GK. 1. ORAL HEARING held on October 7, ALL PARTIES APPEARED at the oral hearing(s). NO ONE appeared telephonically. 3. Claims in the Demand for Arbitration were NOT AMENDED at the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made by the parties regarding the issues to be determined (Stipulations, if any, set forth below). 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: FINDINGS OF FACT: Claimants submitted: Demand for Arbitation dated June 20, 2003; September 10, 2003; and

2 CASE NO. 18 Z October 7, Respondent submitted a letter dated September 9, On March 5, 2002, GK was injured in an automobile accident. As a result of his injuries, GK went to claimants for treatment. On April 26, September 10, October 15, and December 17, 2002, claimants treated GK. More specifically, GK underwent EMG testing and trigger point injections. Claimants submitted the bills for this treatment to respondent for payment. Respondent paid some of the bills but not all of them. As a result, claimants filed this Demand for Arbitration. The issues presented are many: (1) whether or not the fee claimants charged for the EMG testing on April 26, 2002 was the usual, customary, and reasonable fee; (2) whether or not the trigger point injections are payable separate from the office visits; (3) whether or not claimants submitted the bills for the treatment on October 15, 2002; and (4) whether or not the trigger point injections on December 17, 2002 were medically necessary. Regarding the first issue, claimants argue that the fee they charged for the EMG testing on April 26, 2002 was the usual, customary, and reasonable fee. In support of their argument, claimants rely upon the EOBs attached to their Demand for Arbitration as Exhibit B. Respondent, on the other hand, argues that the fee claimants charged for the EMG testing on April 26, 2002 was not the usual, customary, and reasonable fee. In support of its argument, respondent relies upon Ingenix. Regarding the second issue, claimants argue that the trigger point injections are payable separate from the office visits. Respondent, on the other hand, argues that the trigger point injections are not payable separate from the office visits. In support of its argument, respondent relies upon it s argument contained in its submission. As respondent writes, The bill for an office visit in addition to the Trigger Point Injections is improper on the ground that [w]hen a covered injection is provided during an evaluation and management service, only the code for the substance shall be billed. The administration codes shall not be billed because the administration is included in the evaluation and management service. Regarding the third issue, claimants argue that they submitted the bills for the treatment on October 15, In support of their argument, claimants rely upon the facsimile of the bill attached to their Demand for Arbitration. Respondent, on the other hand, argues that it never received the bills for the treatment on October 15, 2002.

3 CASE NO. 18 Z Regarding the fourth issue, claimants argue that the trigger point injections on December 17, 2002 were medically necessary. In support of their argument, claimants rely upon the report of David Rosenbaum, MD dated July 22, It is attached to its September 10, 2003 submission. Respondent, on the other hand, argues that the treatment was not medically necessary. In support of its argument, respondent relies upon its argument contained in its submission. As respondent writes, First Trenton properly denied the trigger point injections done on that day on the ground that the documentation indicates the patient has had trigger point injections April, May and July. It appears the patient continues to have symptoms despite treatment with trigger point injections. CONCLUSIONS OF LAW: Regarding the first issue, I conclude that claimants have proven by a preponderance of the evidence that the fee they charged for the EMG testing on April 26, 2002 was the usual, customary, and reasonable fee. I base this conclusion upon the EOBs attached to claimants Demand for Arbitration as Exhibit B. Regarding the second issue, I conclude that claimants have not proven by a preponderance of the evidence that the trigger point injections are payable separate from the office visits. I base this conclusion upon respondent s argument contained in its submission. Regarding the third issue, I conclude that claimants have proven by a preponderance of the evidence that it submitted the bills for the treatment on October 15, I base this conclusion upon the facsimile of the bill attached to claimants Demand for Arbitration. Regarding the fourth issue, I conclude that claimants have proven by a preponderance of the evidence that the trigger point injections on December 17, 2002 were medically necessary. I base this conclusion upon Dr. Rosenbaum s July 22, 2003 report. Finally, I conclude that claimants are entitled to attorney s fees. Under N.J.A.C. 11:3-5.6(d)(3), an award may include attorney's fees for a successful claimant in an amount consonant with the award and with Rule 1.5 of the Supreme Court's Rules of Professional Conduct. Rule 1.5 states that a lawyer's fee shall be reasonable. The factors to be considered are, among others: the time and labor required, the novelty and difficulty of the questions involved, and the skill requisite to perform the legal service properly; the fee customarily charged in the locality for similar legal services; the amount involved and the results obtained; and the experience, reputation, and ability of the lawyer or lawyers performing the services. In this case, claimants were successful. As a result, claimants are entitled to attorney's fees consonant with the amount of the Award and Rule 1.5. Claimant shall be awarded costs and attorney s fees in the amount set forth in section 10 of this Award. The amount

4 CASE NO. 18 Z awarded also considers respondent s objection to claimant s hourly rate and time expended. 5. MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to Ulises C. Sabato, MD, PA and Neurology & Pain Management Associates, PA $ $ Provider Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. The amount awarded shall be subject to all applicable fee schedules, deductibles, and/or co-payments consistent with this Award. 6. INCOME CONTINUATION BENEFITS: Not In Issue 7. ESSENTIAL SERVICES BENEFITS: Not In Issue 8. DEATH BENEFITS: Not In Issue 9. FUNERAL EXPENSE BENEFITS: Not In Issue 10. I find that the CLAIMANT did prevail, and I award the following COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A. 39:6A-5h. (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $285 for filing fee (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1,150 (C) INTEREST is as follows: Awarded in the amount of $13.33.

5 CASE NO. 18 Z This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. December 4, 2003 Date Barry E. Moscowitz, Esq.