Amputees’ Fight for Insurance Coverage Focuses on ‘Medical Necessity’ of Microprocessor Prosthetics

Washington, DCLucky to live, unlucky to lose a foot or a leg, survivors of the Boston Marathon bombing soon found themselves facing the harsh truth of inadequate insurance coverage for their prosthetic care. Years on, the good news is that microprocessor-enhanced artificial limbs have gotten better. The bad news is that insurance companies like Anthem and United Healthcare still balk at paying for them. Insurance lawsuits since then have taken particular aim at the internal review standards insurers use to determine whether a medical treatment or device is “medically necessary.” The standards do not line up with what amputees need most and what these modern devices can really do. Cost cutting vs. good health – it’s the match of the century.

Fear of Falling

Hearts break at stories of young athletes cut down in their prime or pictures of children born with limb shortages. It’s a loss never quite made right. But most of those who find themselves in the wilderness of prostheses and rehab and insurance and claims and visits to specialists are, in fact, older people. Diabetes is usually the villain. Learning to live and function after losing a foot or a lower leg is a continuing challenge. For many, the fight about quality of care has only just begun after an amputation.
The big fear with an artificial foot or leg is falling. Other mobility complications include compensatory movements (hip hiking), toe dragging, inability to change walking speed when needed, difficulty navigating uneven terrain and trouble walking backwards. It’s bad for the young. It’s worse for the old because the damage compounds. Falling causes fractures, bruises and dislocations. Caution and the resulting lack of mobility triggers other health complications like obesity, further diabetic complications and heart disease. It’s a cascading crisis.

The remedy for this, of course, is to move without fear of falling. A Rand Corp study showed that amputees who receive microprocessor-controlled prosthetic knees have fewer falls and injuries than those who get other, older devices. The study found that microprocessor prostheses users were two times less likely to fall — with a 79 percent relative risk reduction in injurious falls. That leads to fewer fall-related deaths -- about three per 10,000 person years, compared with 14 per 10,000 with older prosthetics. For those who have suffered from limb loss, a sophisticated modern prosthesis may be a safe avenue back into the healthy, active world.

How Anthem Evaluates Medical Necessity

This, however, is not how Anthem evaluates the medical necessity of advanced prosthetics. Their criteria have nothing to do with falls, toe dragging or walking over uneven ground. Anthem is not the only insurer in the marketplace, but by way of example, the guidance to claims reviewers requires that those reviewers select for:

• daily long distance ambulation (for example, greater than 400 yards); and
• regular ambulation on uneven terrain or regular use on stairs. Use of limb for limited stair climbing in the home or place of employment is not sufficient to justify the computerized limb over standard limb applications.

These criteria for approval of a microprocessor-enhanced prosthesis seem to address distance adventuring, climbing the steps at the Washington Monument or bushwhacking – not the real danger of tripping and tipping over on a throw rug.

The Mismatch

The brewing amputee insurance lawsuits are not directed to the question of whether microprocessor-enhanced prostheses meet the existing insurance company standards. Instead, they tackle the difficult issue of whether the standards are correct. As one recent lawsuit alleged:

“[A microprocessor-controlled prosthesis] enhances stability and security for the user, decreases the incidence of stumbles and falls, and provides improved ambulation on all surfaces. The primary advantage of microprocessor technology over the alternative is safety and stability --not speed of ambulation or ability to engage in athletic endeavors. There are other, very different, types of prosthetics whose primary purpose is to increase speed of ambulation and/or maximize athletic performance. Microprocessor knees are primarily for ‘everyday walking around’ activities of daily living and are beneficial and necessary for amputees of virtually every demographic.”

This is a bold legal gambit – challenging the rules themselves, rather than whether the insurance claim administrators applied the rules correctly. It may necessary, however, to break through the insurance companies’ reluctance to recognize the value of, and pay for, modern microprocessor prostheses.