Insurance reimbursement for complementary and alternative medicine modalities

Getting insurance reimbursement for CAM therapies can be tricky, because many insurers limit third-party reimbursement to "medically necessary" therapies, and also exclude "experimental" treatments.

Is chiropractic "medically necessary" for low-back pain? Is acupunture and traditional oriental medicine "experimental?" Does the answer depend on research (clinical trials), or on legislative policy (licensing), or on what an insurance company decides or a court later determines when the claim becomes a civil action?

Some of these insurance reimbursement issues are discussed in Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives, which argues that "medically necessary" is really the wrong concept in an era of integrative medicine that incorporates the best of holistic health and conventional medical care.

An early Texas case, Andrews v. Ballard, canvassed in Legal Boundaries involved the argument that acupuncture cannot be defined as "experimental" for insurance purposes, given its long history of safe use among various cultures.

I recently came across the case below involving a patient seeking eimbursement for colonic hydrotherapy treatments that were denied by the State Health Benefits Commission on the ground that the treatments were "experimental, not medically necessary, for general health maintenance, and administered by an unauthorized provider."

According to the court:

Colonic hydrotherapy is also called colonic irrigation and is similar to an enema, with the difference being the mechanism used and the magnitude of the volume infused. This therapy apparently was known to ancient Egyptians and Romans and has been available in this country for centuries. Murray hopes to establish that treatments, like colonic hydrotherapy, thought to be safe and effective by complementary or alternative physicians, should be reimbursable under the State Plan like treatments that are prescribed by traditional doctors. This appeal, however, is a poor vehicle to accomplish such a result, and we affirm, but nevertheless express some concerns about the rationale the Commission utilized to find that colonic irrigation was an experimental treatment.

After conducting a plenary hearing, Administrative Law Judge R. Jackson Dwyer concluded that Richter was not an eligible provider, and that Murray's treatments after June 27, 1997 were administered merely to maintain his overall health and thus were ineligible maintenance treatments. He further concluded that although colonic hydrotherapy was prescribed by a doctor, the prevailing medical opinion within the appropriate specialty was that such services were not safe and effective. Consequently, colonic hydrotherapy was not a medically needed service. Finally, Judge Dwyer concluded that colonic hydrotherapy could not be considered experimental or investigational under the applicable State Plan definition.

The Commission adopted Judge Dwyer's initial decision completely except it modified his determination that colonic hydrotherapy was not experimental or investigational. The Commission explained its reasoning in the following fashion:

Although there do not appear to be any ongoing clinical trials or research studies, the procedure is nonetheless investigational or experimental. Colonic hydrotherapy is prescribed only by a few doctors practicing integrative or alternative medicine. Since it is not deemed safe and effective by the appropriate specialty, it follows that the procedure needs further evaluation before it would be accepted as appropriate treatment.

In other words, with greater medical acceptance as a safe and effective therapy, the modality could move out of the "investigational" or "experimental" box and the box where one can obtain reimbursement. Of course, there would also have to be a paradigm shift about what is considered "medically necessary" when therapies are included that are not necessarily "medical."


DOCKET NO. A-548-99T3


337 N.J. Super. 435; 767 A.2d 509; 2001 N.J. Super. LEXIS 68

February 7, 2001, Argued
February 27, 2001, Decided

SUBSEQUENT HISTORY: [***1] Approved for Publication February 27, 2001.

PRIOR HISTORY: On appeal from a Final Determination of the State Health Benefits Commission.

Law Offices of Michael H. Cohen offers general corporate legal services, litigation consultation, and expertise in health law with a unique focus on alternative, complementary, and integrative medical therapies.

Michael H. Cohen is Principal in Law Offices of Michael H. Cohen and also President of the Institute for Integrative and Energy Medicine (also known as the Institute for Health, Ethics, Law, Policy & Society), a forum for exploration of legal, regulatory, ethical, and health policy issues involved in the judicious integration of complementary and alternative medical therapies (such as acupuncture and traditional oriental medicine, chiropractic, massage therapy, herbal medicine) and conventional clinical care. The most recent published book by Michael H. Cohen on health care law, regulation, ethics and policy pertaining to complementary, alternative and integrative medicine and related fields is Healing at the Borderland of Medicine and Religion. This is the fourth book in a series, following Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives (1998), Beyond Complementary Medicine: Legal and Ethical Perspectives on Health Care and Human Evolution (2000), and Future Medicine: Ethical Dilemmas, Regulatory Challenges, and Therapeutic Pathways to Health Care and Healing in Human Transformation (2003).

Health care and corporate lawyer Michael H. Cohen has also been admitted to the Bar of England and Wales as a Solicitor (non-practicing), adding to Bar membership in four U.S. states.