Current Status of 3rd Party Coverage and Reimbursement of Sclerotherapy and Prolotherapy
(1978)

Excerpts from a talk presented by Dr. Robert Edmondson, Executive Vice President of Blue Cross/Blue Shield of Pennsylvania at a Tucson, Arizona meeting of the American Osteopathic Academy of Sclerotherapy in 1978.

A letter from C. Everett Koop, M.D., Surgeon and Chief, Children’s Hospital, University of Pennsylvania to Mr. Kates, Field Representative of Pennsylvania Blue Cross/Blue Shield.

Dear Mr. Kates:

This will confirm our conversation in my office several days ago when I discussed with you several of the problems that I have been having in collecting from Blue Shield for treatment of certain patients whose backs I have injected, not only with great success, but to the end, that they avoided a surgical procedure. First of all, let me say that I have been paid for some claims and not for others. It would seem that patients who carry Blue Cross/Blue Shield coverage for a prevailing fee are those bills which are paid for, whereas, others are not.

Let me give you a brief background of the situation. Let me say first of all that I know whereof I speak because I suffer from ligamentous relaxation and have skeletal disability in addition to arthritic changes in my spine. I have, at one time, been paralyzed from this process, and without a surgical procedure, I am now totally able to carry on as a surgeon because of the aforementioned treatment.

The treatment was first described by George S. Hackett and published in a book by Charles C. Thomas in 1956. The procedure has been called by some, Sclerotherapy and by others, Prolotherapy.

I would like to impress upon those who make this decision, that the treatments that I have used on patients not only has produced alterations in their symptoms to the point of complete freedom of symptoms in many cases but has prevented the necessity for operations on patients with similar problems has been proved to be of questionable value.

I will be glad to discuss this with anyone else in your organization that you think should hear it.

P.S. My charge for complicated back injections for the last three years has been $55.00. On a few occasions, Blue Shield has paid $25.00. I should point out that on a few occasions, the injections are carried out in the patient's home under heavy sedation, and the procedure under those circumstances takes at least an hour.

(Dr. Edmondson comments "Picture this if you will, one of the leading pediatric surgeons in Philadelphia at the University of Pennsylvania making house-calls on adults to do Sclerotherapy. C. Everett Koop does what he pleases....His letterhead has ten orthopedic surgeons on it”.)

Response to Dr. Koop from Eddy Conrad, Blue Shield of Pennsylvania.

Dear Dr. Koop:

This letter is in reply to your correspondence of May 31 concerning back injections. This matter has been referred to our Medical Policy Committee and Board of Directors in the past. It was their decision that under the Fee Schedule of Preventative Programs, payment should not be made for Prolotherapy/Sclerotherapy and injection of ligaments. If you have ever received payments under these programs for this service, the clients were paid in error....

Letter from Dr. Koop to Mr. Conrad....

"I have read your letter. The reason I took the trouble to talk to Mr. Kates in person and to send him the long letter which I did was because I know what the past decision of Pennsylvania Blue Shield has been, and I would like the matter reopened. I am not a charlatan and would not have raised the issue with Blue Shield were it not for the fact that I truly believe that the services I render patients in relieving them of pain and numbness should be compensable. Furthermore, in reference to Prolotherapy, I have personally "been there”. If at the time when I was having severe pain in my right arm and had lost the power of my right forearm I had undergone the cervical spinal fusion that was recommended, I would have been in a great risk, and Pennsylvania Blue Shield would have paid the bill. Instead, I have had a medical spinal fusion, am free of pain, have lost my paralysis and regained the use of my right arm, all without risk to myself.

It seems to me that a physician is entitled to Blue Shield payment for such remarkably effective therapy. If it is possible to reopen this issue with the Medical Policy Committee, I would appreciate it."

Sincerely,

C. Everett Koop

Response to Dr. Koop from Pennsylvania Blue Shield.

Dear Dr. Koop:

“I am pleased to tell you that we are reopening the matter of back injections as you have described in your recent letters. Our first step is to contact our Medical Advisors."

Dr. Edmondson indicates that there were some questions that went out to five advisors for Blue Shield who were all orthopedists. Dr. Richter of Blue Shield then wrote to the Pennsylvania Orthopedic Association and received all negative responses.

Dr. Richter then wrote back to Dr. Koop.

Dear Dr. Koop:

This letter regards your inquiry regarding injection of an irritant solution. The information you sent us was forwarded to the Advisors. At the suggestion of one of our Orthopedic Advisors, we wrote to the Orthopedic Society because one of their committee addressed this problem at task. He agreed with our Advisors' opinion that no allowances should be made by Blue Shield for this service since it is not a generally accepted or clinically recognized procedure. For this reason, no further action will be taken on our present policy of rejecting payments for this service."

Dr. Richter

Dr. Koop then responded to Dr. Richter.

Dear Dr. Richter:

“I appreciate you writing me as you did on September 1, though, I cannot say that I liked the content of your letter. The older I get, the more irritated I become with the establishment in organized medicine, and I fear that I must include Pennsylvania in that, I am overly committed in my surgical endeavors, but before I retire, or perhaps afterwards when I have a little more time, I feel I will be forced to take my concerns to the public. I suspect that most of the medical profession and the public have enough confidence in my integrity to listen to me. My concerns are not the economics of recovering a fee for injecting backs, rather, I am concerned about why your Advisors have advised as they have. I suspect I know.

Respectfully yours,

C. Everett Koop

Dr. Edmondson went on to say that what the insurance companies pay for becomes the standard of medical care. He outlined the strategies for influencing change in 3rd party coverage and the medical standard of care. They were: 1. Request reconsideration. 2. Get documentation of effectiveness. 3. Controlled clinical trials. 4. Political effectiveness.