Are Trigger Point Injections Covered by Florida PIP?

Question from CurlyCue, Are Trigger Point Injections Covered by Florida PIP?

Answer from AI:

Determining whether trigger point injections are covered under Florida’s Personal Injury Protection (PIP) for medical services involves understanding the specific provisions of the Florida Motor Vehicle No-Fault Law, the terms of the insurance policy, and the billing practices of insurance companies.

Understanding Florida PIP Coverage

Florida’s PIP coverage is designed to provide immediate medical benefits to a driver or passengers injured in a motor vehicle accident, regardless of who is at fault. PIP coverage typically includes a portion of medical expenses, lost wages, and death benefits.

Reviewing the Insurance Policy

• Policy Language: The first step is to review the language of the PIP insurance policy. Insurance policies can vary, and coverage for specific procedures like trigger point injections may be explicitly included or excluded.
• Medical Necessity: Even if the policy covers such treatments, they must be deemed medically necessary according to the terms of the policy and the standards set by the insurance company.

Medicare Fee Schedule Reference

While the Medicare fee schedule can provide a reference for covered services and reimbursement rates, it does not directly dictate what private PIP insurance must cover. However, it can serve as a guideline for what is generally considered a standard medical service.

Insurance Payment History

• If trigger point injections have consistently not been paid by various insurance companies, it may indicate that these companies do not consider the procedure to be covered under their PIP policies or do not recognize it as medically necessary.
• It is important to review the Explanation of Benefits (EOB) statements provided by the insurance companies for specific reasons for denial.

Seeking Payment

• Direct Billing: Typically, PIP insurance pays medical providers directly for covered services. If a service is not paid, it may be due to a coverage exclusion, a billing error, or a dispute over the necessity of the service.
• Settlement: If the insurance does not cover the injections, payment might come from a settlement if the injured party pursues a claim against the at-fault driver’s liability insurance. However, this is separate from PIP coverage and would be part of a legal process.

Next Steps

1. Review the specific PIP policy language for coverage details.
2. Examine the EOBs for reasons for denial and consider appealing the decision if appropriate.
3. Consult with a legal professional who specializes in insurance claims and personal injury law for personalized advice.
4. Consider contacting the Florida Department of Financial Services or the Florida Office of Insurance Regulation for assistance with insurance-related issues.

It is recommended to seek legal advice from a qualified attorney or a healthcare law specialist to understand the nuances of your situation and to determine the best course of action. Legal professionals can provide guidance on interpreting policy language, appealing insurance denials, and pursuing payment through legal channels if necessary.