Health insurers are limiting coverage for prosthetic limbs, raising concerns about medical necessity and access for those in need.
But when he needed a new leg last January, his new insurance plan said, “Nope, not medically necessary.” Can you believe that? Even though his doctor has been prescribing that type of leg for years, the insurer just wouldn’t budge. Michael said that without the electronic knee, it would feel like going back to a wooden leg, which is a huge step back for him.
It’s wild how people needing joint replacements don’t face the same issues. In 2021, tons of knee and hip replacements happened without a hitch. But for those in the amputee community, it feels like discrimination. A doctor pointed out that insurance covers a knee replacement if it’s covered with skin, but not if it’s plastic. That’s just unfair.
The trade group for health plans claims they cover prosthetics when they’re deemed medically necessary. But the reality is that coverage varies a lot. Some plans might cover basic prosthetics but then put caps on what’s available. It’s frustrating, especially since there are millions of people living with limb loss in the U.S., and that number is expected to double soon.
Many folks with limb loss don’t even get prescribed a prosthesis. Insurers often deny coverage, saying it’s not medically necessary or experimental, even though these advanced knees have been around for ages. There’s been some progress, like a Colorado law that requires insurers to cover prosthetics, but it only applies to certain plans.
Even Medicare covers 80% of prosthetic limbs, but a recent report showed that only 30% of people who lost a limb got a prosthesis in the following years. Cost is a big issue too. Most people still have to pay something out of pocket, which can lead to payment plans or loans.
Michael ended up paying about $4,000 for his new leg after an appeal. He was lucky to afford it, but not everyone is in the same boat. Take Leah Kaplan, for example. She was born without a left hand and finally got a prosthetic hand a few years ago. But when she tried to get another one for daily use, her insurance denied it, claiming it wasn’t necessary.
She’s been fighting with her insurer for approval, but they’ve turned her down multiple times. It’s a tough situation, and she feels defeated after waiting so long. It’s just a reminder of how complicated and frustrating the whole insurance process can be for people who really need these devices.
