A year and a half ago, I was sitting in my prosthetist, Derick’s, office excitedly anticipating the retrieval of my new prosthesis. The artificial leg that I was wearing was 6 years old and had seen better days. The lock in the bottom of the socket had worked itself loose, which meant it had trouble staying attached. My doctor had told me that my insurance company would likely deny this new prosthesis because I was “too healthy.” What did that even mean? Since when is that a bad thing?
I came to find out that “a controversial Medicare rule proposed in 2016 turned back the style of healthcare for America's amputees. It was designed to follow a 1970's style health care plan that would not benefit current day amputee needs. When this proposal was released, the American Orthotic and Prosthetic Association (AOPA) warned private health care insurers would exploit this new rule. It was reported shortly after the release of the proposal that giant healthcare providers, United Healthcare and Cigna began denying coverage to amputees” (“Prosthetic Limb”). Despite the new Medicare rule, insurance approved my prosthesis on the first try. I thought I was getting off scot free, but I certainly didn’t anticipate the long, tangled road that I would go down only months later.
The excitement of the new prosthesis quickly wore off only weeks later when the suction stopped holding it on. For one reason or another, my residual limb (what I call my stump) must have changed shape enough to break the suction. In fact, when I was leaving a movie night at my daughter’s elementary school, my prosthesis completely fell off as I went down the bleachers. Thank God a man was sitting near enough to grab my arm before I fell on my face.
After ten different trips to see Derick to make adjustments to the socket and suction suspension, we both determined that it wasn’t able to be salvaged. Unfortunately, we had spent an entire year trying to fix the prosthesis that it was now out of warranty. He knew that getting a new prosthesis approved after only one year was going to be an uphill battle. Derick told me that we had to show insurance that it was a medical necessity because “insurance compan[ies] will not want to pay more than is medically necessary and will even attempt to get out of paying completely” (“Prosthetic Limb”). So, he went to work drafting a sound, honest claim for a new device. Unsurprisingly, after two short weeks, the claim was denied. Insurance said that the foot was still under warranty for two more years, so they wouldn’t pay for a whole new prosthesis. However, what insurance didn’t realize is that Derick couldn’t make me a different socket that could still use that foot because we were unable to use suction. He wanted to go with a different method of attachment because suction hadn’t previously worked. But, because my stump is so long, that taller foot wouldn’t fit under a new socket that wasn’t designed for suction. In other words, that foot might as well have been a $7,000 paperweight; it was essentially useless.
My doctor and Derick knew the inner-workings on the insurance debacle way better than me. I was aware I wasn’t the first amputee to be denied their crucial prosthetics, but I didn’t know the severity of the situation at that time. Take Rob Rieckenberg, a 37-year-old amputee from Minneapolis, for example. He “lost a leg after he was mugged and left on a train track where he was struck by a train. He has a vacuum suspension socket and sought continued care through employer-provided group insurance with United Healthcare. Rieckenberg said: ‘In the wake of the draft Medicare rule, United Healthcare was going to deny me coverage. So I had to buy an individual plan through Blue Cross. I’m paying five times as much for premiums because United wouldn’t have extended me the coverage I am due. I had to have a vacuum suspension because of the skin grafts on my stump. Any less-advanced technology would tear up my skin’” (“Press Release”). Insurance companies deny amputee’s devices with little knowledge of the individual’s circumstance, the fitting process, or even the technology on a regular basis.
Because I was denied, I was forced to wear my broken, now seven-year-old prosthesis. I did that for six months. It started off ok...until it wasn’t. Because it wasn’t fitting correctly, I started getting abrasions everywhere on my stump. Walking to the mailbox each day became a painful, laborious task when before, when my prosthesis was fitting, I would engage in vigorous exercise on a daily basis. It wasn’t just my prosthesis that was broken— I was! My mood was sour; I felt defeated and useless. I know that seems like hyperbole, but it’s not. I couldn’t walk the dog, help my kids get what they needed, or even go grocery shopping. I wasn’t used to using crutches and I didn’t have access to a wheelchair. I realized more than ever that my mobility affects my happiness and worth. Insurance took that away from me.
Additionally, Derick was presented with the impossible task of fixing a prosthesis that had no business being fixed. It was beyond repair, but Derick did the best he could. We didn’t have another option (unless that option was to pay $12,000 out of pocket). He reattached the lock for the third time with an adhesive silicone. Then, he cut the socket in any place that was causing me pain. What was the result? A prosthesis that had its structure compromised. It had more holes than it did plastic. Thankfully, Derick’s repairs were enough to hold me over until insurance finally came to its senses.
Anthem Blue Cross and Blue Shield is doing similar things to other amputees by “refus[ing] to pay for the more expensive C-Legs, because they were experimental and not medically necessary. More than 25,000 C-Legs have been used by amputees. ‘Sometimes a treatment will be thought of as mainstream for a particular patient population, but it will be thought of as experimental for a different population,’ said Susan Pisano, a spokeswoman for the insurance lobbying group America's Health Insurance Plans in Washington, D.C. Bailey said she fought with Anthem for 10 months, filing two appeals, which the company denied. ‘It was tearing me up inside that I had just been told no for something that I really, really need,’ she said. ‘To live my happy life in the same way that I was living it in June 2007.’ There are nearly 2 million amputees in the United States, and most health insurance policies do a poor job of covering prosthetics for them, said Patty Rosbach of the Knoxville, Tenn.-based Amputee Coalition of America, an advocacy group that works on behalf of people who've lost limbs” (Cuomo). I simply wouldn’t allow my insurance company to do such a poor job. Do they need to worry about frivolous spending? Sure! Is my prosthesis unnecessary and frivolous? Absolutely not!
Prepared for a fight, Derick and I regrouped and tried a different approach with insurance. Thankfully for me, we didn’t need to fight any further. They finally admitted the need for the new prosthesis and approved my claim. However, as I read the paperwork more closely, I realized that they only approved one test socket. One! During the last fitting process a year and a half ago, I went through three test sockets only to have the final product still not work. I immediately texted Derick and said, “I guess my insurance company thinks you’re perfect and that it’s an easy process to make a prosthesis. Haha I hope you hit a home run on the first pitch!” He responded with, “We are getting more and more of those test socket denials. They’re so clueless.”
Test sockets are clear and pliable to make it easy for the prosthetists to make minor changes before finishing it out to the end product. They can heat up the plastic and push certain parts out that are causing the patient pain. However, there are times when major changes are necessary and a new test socket needs to be made. It’s way cheaper to make another test socket rather than to replace a completely finished, more expensive prosthesis. But, insurance companies don’t know the complexity of the fitting process. Not all amputees are the same. Our bodies are vastly different. I am extremely hard to cast and fit properly because of my long, skinny, bony stump, which is highly unusual. I have so many “hot spots” that it’s difficult to make a comfortable fit. Certain patients need more than one test socket covered, whereas others probably don’t. But, insurance companies deny ALL additional test sockets, requiring amputees to appeal their claims. That process can be lengthy, which just delays the fitting process even more. That results in the amputee being uncomfortable and having a lower quality of life.
I’m not saying that insurance companies should approve all things amputee related. I simply think they need to look at every patient’s circumstance before denying claims and make an informed decision. They need to become more knowledgeable about the whole field of prosthetics and refrain from making decisions purely based on their financial burden. I pay for the highest insurance premium that my employer offers because it covers more of my device (80/20). I already pay an exorbitant amount of money (including my deductible) and normally only require a new prosthesis every 5 years. Because I am otherwise healthy and don’t really use my insurance for much else other than visiting my doctor for a sinus infection every once in a while, I think my insurance company can pay for a prosthesis that I need without having to jump through an ungodly amount of hoops.
Works Cited
Cuomo, Chris, and Gerry Wagschal. “Amputee Fights for Coverage of Prosthetics.” ABC News,
ABC News Network, 13 Jan. 2009, abcnews.go.com/GMA/TheLaw/amputee-fights-coverage-prosthetics/story? id=6640663.
“Press Release: AMPUTEES NOW BEING DENIED COVERAGE BY PRIVATE INSURERS
BASED ON WIDELY CRITICIZED AND UNFINALIZED MEDICARE RULE.” AOPA, 21 Apr. 2016,
www.aopanet.org/2016/04/press-release-group-amputees-now-being-denied-coverage-by-private-insurers-based-on-
widely-criticized-and-unfinalized-medicare-rule/.
“Prosthetic Limb.” Stop Insurance Denial Law Firm, 2020,
www.stopinsurancedenial.com/services/limb-denials/prosthetic-limb.