Amputees Fight for Insurance Coverage

Amputees in many states may not have the cost of their new, permanent limbs covered by their insurance plans. This has sparked a nationwide campaign by amputees and the prosthetics industry to get Congress and the individual states to demand more comprehensive coverage for prosthetics, especially those that are now enhanced with microprocessor technology. Lawsuits are underway against Anthem, Blue Shield and United Healthcare in California and other states.

A recent case in South Burlington, VT, for example, highlighted the problem when a cancer survivor found she would have to pay for the cost of a new right leg, after having lost her natural leg to cancer. Her insurer told her that she had already spent her $10,000 lifetime coverage on a temporary limb, and they would not cover the cost of a permanent one.

As many as 2 million Americans have lost a limb, largely due to diabetes. A prosthetic can cost between $3,000 and $40,000, depending on how mechanically advanced it is. Furthermore, most amputees can count on being re-fitted with a new prosthetic as frequently as every three to five years, so this is not a one-time cost.

In addition to the lifetime cap issue, insurance companies often deny coverage for the new “smart” prostheses. The denials typically cite two reasons: the experimental, investigational status of the advanced devices, or that they are not medically necessary.

Advanced microprocessor-assisted devices respond to subtle changes in walking speed and the type of terrain being navigated. RAND Corp. reports that adjustments made in real time improve the wearer’s stability, decrease falls and stumbles and lessen the discomfort often associated with using a prosthetic.

Microprocessor knees, legs and ankles have existed in evolving form for approximately 20 years and are now routinely prescribed for lower-limb amputees. Nonetheless, Anthem declines coverage for these devices as “investigational” on the basis the basis of its internal guidelines. Specifically, the insurer has determined that they do not improve patient outcomes because there has been no showing that they improve an amputee’s ability to walk very quickly or for unusually long distances.

Using the same criteria, Anthem similarly disputes whether microprocessor prostheses are medically necessary.

From a wider viewpoint, however, what is “medically necessary” may depend on what condition of life a prosthesis is expected an amputee return to. Recent lawsuits have featured younger, more athletic amputees who find that they might fight their insurance carriers for coverage of the kinds of prostheses appropriate for running, cycling or swimming. The same logic could be applied by amputees who fight for insurance coverage for advanced devices that improve mobility, safety and comfort in the performance of more mundane tasks.

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Last updated on Sep-27-18