Does insurance cover CAM treatments?

Some private insurers have begun to recognize the value (medicinal or consumer) of certain CAM therapies, and may cover, partially cover, or offer negotiated discounts for specified CAM services. Acupuncture and nutritional counseling are two examples of a very small group of fairly "mainstreamed" CAM services.

The majority of CAM therapies are not currently covered by conventional health insurance, even with the public’s strong demand for complementary and alternative treatments. The reason? There is an enormous void of scientific evidence delineating treatment efficacy and outcomes, as well as a lack of professional regulation and credentialing for most CAM practitioners. Traditional Chinese medicine, reflexology, herbalism, and mind-body techniques are a few of many therapies people are accessing for which little scientifically recognized evidence of benefit is available. Yet, some modalities have acquired a significant amount of scientific evidence to back their claims, and are more commonly used. For example, an NIH consensus panel found that clinical studies have shown acupuncture to be an effective treatment for nausea caused by surgical anesthesia, cancer chemotherapy, and dental pain experienced after surgery. The panel also found that acupuncture is useful by itself or combined with conventional therapies to treat addiction, headaches, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, lower back pain, carpal tunnel syndrome, and asthma. Additionally, acupuncturists in 35 states must meet specific requirements in order to obtain state licensure, certification, or registration to practice. Health plans are neither willing to invest in nor endorse treatments to patients that are unproven and unregulated, no matter how "successfully" the treatment has been administered in its traditional system.

Indeed, more and more insurers are slowly adding CAM services and programs in response to consumer demand. At a May 2001 meeting of the White House Commission on Complementary and Alternative Medicine Policy, insurance representatives speculated that the changing racial, ethnic, and cultural makeup of the American workforce brings new attitudes, expectations, and beliefs to the health care table. Employees request certain health care benefits from their employers, who, in turn, negotiate with health insurers to include these new services in the policy. Employers recognize the importance of offering desired benefits in order to recruit and retain valuable employees. Government-sponsored insurance, on the other hand, is not shaped by consumer demand, but by legislative mandate. The statutory language of Medicare prohibits payment for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury" {Section 1862(a)(1)(A) of the Social Security Act}. All coverage decisions are based on this statute; for that reason, Medicare traditionally does not pay for preventive services. If Congress mandates coverage for certain treatments, as it did for Pap smears, mammography, and colorectal screenings, then Medicare would indeed have to pay for them. Government analysts predict legislative mandate is the only way CAM treatments would ever be included as Medicare benefits. But, the government, just like private insurers, would require strong evidence of the treatments’ safety and efficacy, as well as practitioner competency and professional regulation.

Source:
National Commission on Complementary and Alternative Medicine
http://www.NCCAM.nih.gov
National Institutes of Health Consensus Panel. Acupuncture. National Institutes of Health Consensus Development Statement (Bethesda, MD, November 3-5, 1997)

White House Commission on Complementary and Alternative Medicine Policy, meeting transcript, May 14, 2001 (Ms. Joy Johnson Wilson, Counsel and Director of Health Committee, National Conference of State Legislatures)