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Special Report
American Chinese Medicine Association (ACMA)
On Chinese Herbal Medicine (CHM) About Doctor of Chinese Medicine (CMD) Education
January 23, 2006 American Chinese Medicine Association (ACMA) received a severe arthritis patient who was put on the knee transplant surgery list before visiting ACMA. The patient got arthritis about 20 years ago. Both knees were affected. Since then, the patient had been seeking Western Medicine treatments continuously. However, all Western Medicine treatments failed, and her knee pains got worse and worse. Knee pains were continuous 24 hours a day, 7 days a week, and pain got deteriorated during rainy days and weather changes. The patient could not walk as a normal person, and lost mobility for 5 months. By January 2006, the patient's knee pains got so severe that the knee transplant surgery was indicated and her MD doctor planed to do knee transplant surgery for her. Before doing the knee transplant surgery, the patient was referred to ACMA by several relatives and friends. The patient put her last hope into the Chinese Herbal Medicine (CHM) treatments at ACMA. If the CHM treatments at ACMA failed too, she would have no choice but to do the knee transplant surgery.
March 8, 2006 After one and half months CHM treatments at ACMA, the patient's knee warm feeling was gone, swollen was reduced by more than 60%, knee pain was reduced by more than 50%. The patient's overall condition has been significantly improved, and the knee transplant surgery can be avoided. Based on above successful CHM treatments at ACMA, the patient requested ACMA to submit a predetermination application to her insurance company BlueCross BlueShield of Illinois (BCBS of IL) to cover her CHM treatments.
March 17, 2006 ACMA sent the predetermination application to BCBS of IL.
April 5, 2006 BCBS of IL denied her application for the following reason: "... because there are inadequate published data to permit scientific conclusions regarding improved outcomes (referring to the CHM treatment imporvements). ..."
April 17, 2006 ACMA faxed BCBS of IL ten publications (in English) on CHM treatments for the patient's disease.
April 27, 2006 BCBS of IL denied the patient's application again. This time, BCBS of IL did not mention "... because there are inadequate published data to permit scientific conclusions regarding improved outcomes. ...". Instead, the new denial reason became: " ... the proposed procedure (CHM) is excluded under your coverage agreement. ..."
May 4, 2006 ACMA was surprised that BCBS of IL had a policy singling Chinese Herbal Medicine (CHM) out and excluding it. ACMA then called BCBS of IL provider line requesting a copy of its agreement/policy excluding CHM. The BCBS of IL provider line representative replied that he was unaware the policy excluding CHM. He said the predetermination application is primarily decided based on medical necessity. ACMA was surprised that the BCBS of IL provider line representative's reply and the BCBS of IL's letter were inconsistent in the following aspects: (1) BCBS of IL's letter denied the patient's application based on their agreement/policy excluding CHM, while the BCBS of IL provider line representative was unaware such agreement/policy; (2) BCBS of IL provider line representative said the decision on predetermination is primarily based on medical necessity. However, the BCBS of IL's letter never mention medical necessity. Instead, the first denial letter used the excuse of "... because there are inadequate published data to permit scientific conclusions regarding improved outcomes. ...". The second denial letter used the reason of " ... the proposed procedure (CHM) is excluded under your coverage agreement. ...". None of them addressed the most important criterion -- medical necessity. Then, ACMA submitted a letter to BCBS of IL requesting:
May 5, 2006 Another issue to ACMA surprise was that the patient had never received a copy of the membership insurance agreement/policy from BCBS of IL since the beginning when the patient became a member at BCBS of IL. Since the patient had never received a copy of the insurance agreement/policy, the patient called BCBS of IL member line to request a copy of the membership agreement/policy. The BCBS of IL member line representative replied to the patient that there was no written policy sending out to the patient. The representative let the patient go to the patient employer's Human Resource Department to get a copy of the policy. Whatever the Human Resource Department had was what the patient could get. Then, the patient went to the Human Resource Department. The Human Resource Department did not have comprehensive policy book either. All the Human Resource had was a simple printout from website which gave very little information on the complete insurance policy.
May 9, 2006 The patient reported above situation to ACMA. In the meantime, another patient also reported to ACMA a similar situation (the second patient had never received a copy of the insurance policy from BCBS of IL either). To clarify above issue, ACMA contacted the state and federal insurance regulatory agencies. Both agencies told ACMA that it is illegal for insurance company to withhold insurance policy. The laws require insurance company to disclose policy to all patients. Afterwards, ACMA sent a letter to BCBS of IL requesting it to provide insurance policy to all ACMA patients at BCBS of IL. To help ACMA patients obtain insurance policy, the U.S. Department of Labor Employee Benefits Security Administration then sent ACMA a form letter. The form letter and U.S. Department of Labor Employee Benefits Security Administration contact information have been published at ACMA website. You may download the form letter as follows: (1) (2) click "Forms" (3) click "Legal"
May 30, 2006 The patient's knee pain was completely stopped during regular days. Pain only exist mildly during rainy days. The patient can walk as a normal person, and mobility has been regained. The patient can function as a normal worker at her work place. The patient is very satisfied with the CHM treatments at ACMA, which saved her from receiving knee transplant surgery.
June 2, 2006 The patient reported to ACMA that she has filed an appeal against BCBS of IL's denial of her CHM insurance coverage request. She said she has been a member at BCBS of IL since early 1980s. For about 20 years, all her previous failed treatments (Western Medicine treatments) were covered by BCBS of IL. Now she has met and received the only treatment that helps and works for her -- the CHM treatment, which has improved her condition significantly and saved her from receiving knee transplant. However, BCBS of IL denied the CHM treatment coverage. It turns out that the BCBS of IL covered what did not work, and denied what works. She believes this is inappropriate and wrong. She deems that BCBS of IL should cover the effective CHM treatments.
Generally speaking, insurance predetermination is based on medical necessity primarily. According to the medical necessity criteria, above case is quite simple because the patient's medical necessity is very well established. Following is a brief description on the case's medical necessity (due to privacy consideration, the case's details are omitted.) The patient got arthritis about 20 years ago. Both knees were affected. Since then, the patient had been seeking Western Medicine treatments continuously. However, all Western Medicine treatments failed, and her knee pains got worse and worse. Knee pains were continuous 24 hours a day, 7 days a week, and pain got deteriorated during rainy days and weather changes. By January 2006, the patient's knee pains got so severe that the knee transplant surgery was indicated and recommended by her doctors. On January 23, 2006, before doing the knee transplant surgery, the patient was referred to ACMA by several relatives and friends. The patient put her last hope into the CHM treatments at ACMA. If the CHM treatments at ACMA failed too, she would have no choice but to do surgery. After a few months CHM treatments at ACMA, the patient's knee warm feeling was gone, swollen was almost gone, knee pain was stopped during normal days. Pain only exist mildly during rainy days. The patient's overall condition has been significantly improved, and the knee transplant surgery can be avoided. To BCBS of IL, the patient's previous 20 years claim records are evidences to show that the Western Medicine treatments in the past 20 years failed. Therefore, BCBS of IL is very clear that the patient's condition had been deteriorating through the past 20 years. In contrast to previous 20 years Western Medicine treatments, the CHM treatments at ACMA changed the course of the patient's condition. BCBS of IL understands that there is no doubt that the case's medical necessity has been soundly established. However, BCBS of IL has never mentioned medical necessity criteria in its denial letters. Instead, BCBS of IL switched to other excuses in its denial letters: (1) In the first denial letter, the reason was inadequate publications on CHM treatments. (2) After ACMA submitted 10 publications (in English) to BCBS of IL, its second denial letter did not mention inadequate publications any more. Instead, the new denial excuse became a BCBS of IL agreement/policy excluding CHM. Currently, ACMA has requested and is waiting for BCBS of IL to provide its agreement/policy excluding CHM.
ACMA was surprised that the BCBS of IL had a policy singling Chinese Herbal Medicine (CHM) out and excluding it. From legal viewpoint, singling a medicine (e.g. CHM) out and excluding it probably is violating laws (e.g. discrimination). This is a very serious issue to the entire profession of Chinese Medicine as well as millions and billions of CHM patients in the world. ACMA has requested the BCBS of IL to
On Chinese Herbal Medicine (CHM) BCBS of IL has a policy excluding CHM. In order to judge whether this policy is justified or not, please visit On Chinese Herbal Medicine (CHM), ACMA Publication Issue Jan 1, 2006. The conclusion is that from science and medicine viewpoints, excluding CHM is against science, medicine, and counter productive to the advancement of human civilization.
About Doctor of Chinese Medicine (CMD) Education BCBS of IL has a policy excluding CHM. In order to evaluate this policy, please visit About Doctor of Chinese Medicine (CMD) Education, ACMA Publication Issue Aug 1, 2004.
Under ACMA's pressure, BCBS of IL finally corrected its words on CHM, and removed the words "exclude CHM" from its letter. BCBS of IL changed its words to BCBS of IL does not cover CHM. ACMA wishes BCBS of Illinois will learn from this incident, respect CHM and billions of CHM patients around the globe, and make sure similar incident will not happen again.
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