Get the Help You Deserve if Insurance Denies Your Prosthetic Limb

Amputees across the country are being denied their insurance claims for needed prosthetic limbs. Some of the major insurance companies are claiming there is a lack of evidence supporting the need for patients to have more modern prosthetics. Fighting big insurance companies to gain necessary prosthetic limbs is a difficult challenge.

If you or someone you know has been denied a prosthetic claim by your insurance company, you will need a personal injury attorney on your side. These denials cause shock, anger and a sense of helplessness. You need someone familiar with insurance company policies to stand up against the big insurance company and get the coverage you deserve.

Insurance companies have a lot of exclusions on their policies. You have to read your specific plan to know and understand what you have for coverage and what you don't. The Amputee Coalition of America states that insurance companies routinely deny the more expensive prosthetic models.

Problems Caused by a 2016 Medicare Rule

A controversial Medicare rule proposed in 2016 turned back the style of health care 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. After a lot of criticism, Medicare and Medicaid Services reported they would study the rule, but did not withdraw it. As expected, private insurers began to exploit their coverages.

As recently as this past spring, insurer Anthem denied a claim stating a device was not medically necessary if it is not appropriate for the treatment of a specific condition. It claimed the denial was based on not being appropriate in terms of site, duration, type, frequency, and extent of the patient's injury. They further stated the benefit that was hoped to be gained by the patient did not outweigh any risk of harm to their health.

This insurance company, Anthem appeared to have evaluated the medical necessity for this prosthesis on whether or not the patient demonstrated a need to walk fast and for unusually long distances. Neither of these reasons was why the patient needed the device.

Proving Medical Necessity

Medical necessity equals your unmet medical needs plus why and how the device you are requesting meets your current unmet needs. This information is added to the proof or evidence that the device you are asking for will meet your unmet medical needs better than a less sophisticated or expensive device.

Proving medical necessity for a prosthetic limb is necessary because your insurance company will not want to pay more than is medically necessary and will even attempt to get out of paying completely.

Medical necessity is also needed when your insurance decides they want you to use a similar device because it is cheaper but not necessarily better. There are devices on the market that will perform the same, but their quality is not the same. When you sit down to prove medical necessity there are eight things to remember:

  • Review the criteria of your coverage with your insurance company and ensure you check all boxes necessary to cover your medical needs.
    • Medical reviewers are forced to follow administrative procedures and will have to justify their decisions to their superiors. If you don't meet some or all of the coverage requirements in the policy, the reviewer will have a difficult time approving your claim. By checking and listing all the criteria of your coverage, you will make it easier for a reviewer to accept your application.

  • Think before you answer questions and put them in writing.
    • Whatever information you write down will be used against your claim by medical reviewers. You don't want to cover up any issues, but at the same time not overwhelm reviewers with too much information.

  • When you list facts about your condition, you want them to be easy to spot by a reviewer of your claim.
    • The quickest way to frustrate a reviewer is to blog them down with too much information. This overload of information could lead to essential factors being ignored or negative aspects being highlighted and exploited.

  • When justifying your medical needs, you want to be to the point and keep them brief.
    • A reviewer is only given approximately twenty minutes for each claim. They do better handling requests that only four to five pages in length, so you want to keep your information brief and not bogged down with a lot of technical jargon.

  • Whatever information you list in your claim must match those of a referring doctor.
    • Make sure your doctor knows the criteria of your coverage and what information needs to be documented in their records. You will want to secure a correct prescription for what you are requesting. Compare your notes with those of your doctor's and make sure there are no inconsistencies or discrepancies.

  • Do not let descriptions become lengthy as reviewers may tend to skim the document and miss important information.
    • Keep your medical necessity brief and focus on relevant facts. One good thing to keep in mind is to avoid repeating any points. The technology behind the device you are requesting is not what will drive the decision to approve.

  • Focus the information on your needs that have been met and how the prosthetic device requested is going to meet your needs functionally without getting too technical.
    • The fact that it is 'state-of-the-art' will not impress a reviewer and encourage them to approve your claim. Don't waste your time or theirs; you need to focus on facts that matter to the insurance company. List your unmet safety and mobility needs and define a goal for fitting the requested device.

  • Back up all the information you put on the claim on a device that ties to your unmet medical needs.
    • Be able to back up your need for the specific device you are requesting. For example, it will reduce your risk of falling or improve your balance. Other benefits could be that it will enhance your walking performance and capabilities. Whatever benefits you expect to get from this device should be highlighted for the reviewer.

How Many People are Affected by Insurance Denials of Prosthesis?

There are more than 180,000 amputations each year which break down to roughly five hundred amputations a day. Not all amputees choose to receive a prosthetic due to the difficulty in learning how to work with them; however, new advances are making them easier to learn and live with.

New technology is introducing microprocessor prosthetic enhanced artificial limbs, but the costs of these new advancements are quite high. Insurance companies are fighting the coverage of these more modern, 'smart' style prostheses. There are currently organizations fighting this decision, and activist amputees are organizing to fight this issue.

If you have been denied coverage for a prosthetic, or someone you know has been denied coverage, contact a personal injury attorney to help with filing your claim. Insurance companies have attorneys on their side, and you deserve to have someone helping you to get the coverage deserved.

Amputees need all the support possible when learning how to navigate the world in a whole new way, and insurance companies are making it difficult for them. Healthcare today is a complicated process and with the expense involved with prosthetic, insurance companies are working hard at finding ways to deny coverages.

These are common reasons insurance companies are not covering amputee claims:

  • The insurance reviewer finds that the device is not medically necessary. In a situation like this, it may be required to get a second opinion to back up the necessity from another doctor. Ensure the physician documents exactly 'why' they feel you need the device.
  • The insurance company did not receive adequate paperwork. Contact the insurer to ask precisely what information they still need to file your claim. You may have missed some detail on the claim that rejected your paperwork. Complete the resubmission right away as timing is everything in the insurance world.
  • The insurance company finds you did not use a physician within their network. You must have pre-approval from your insurance before seeing physicians outside of their listed network. Have the right documentation for your condition if you need to justify not being able to wait for an 'in-network' doctor.
  • The insurance company has determined your request involves experimental treatments. Insurance companies can cover experimental therapies if you are able to prove it is medically necessary and considered standard within the medical community. It is the only treatment available that will work for your situation, and the treatment has been covered under the same plan for other patients.
  • The insurance company is stating your policy expired for lack of payment. There are situations where payroll does not get the premiums paid on time, or you may have opened a new bank account, and the payment system didn't transfer over in time, or other situations arise that may have caused your premium to be late or missed. Contact your insurer and explain along with providing them with documentation as to what happened to cause the premium to be late. It can also help to remind them of the number of years you have faithfully paid on your policy.

Life becomes even more frustrating when you file a claim; only to be told your insurance won't cover you. There is hope; however, as you can appeal their decision. Contact a personal injury attorney to help you through this denial process.

How to Work with an Insurance Company

Getting an insurance company to cooperate with you is often difficult. The best experiences come from:

  • understanding the rules, they have established for filing claims
  • speak politely with the representatives
  • act professionally when discussing their decisions
  • remain persistent with your requests
  • be firm until you get the results you deserve

When choosing an insurance company, you want to familiarize and review their policies carefully. Know which healthcare professionals they will allow you to visit, and whether or not the doctor you have been working with is included in their 'network'. If your doctor is not in their network, find out what the policy is, or if it is possible, to work with a physician 'out-of-network'.

Talk to several companies when looking for new companies and get a sense of how you will be treated as a patient when you have to file a claim. Go through the policy and ensure what is listed is what you can expect to get approval for when submitting claims. There are times patients file an insurance claim only to hear the company is no longing covering that type of procedure, so you want to get a guarantee on coverages listed on the policy.

An insurance company is a business and just like all other businesses, they don't like paying out money. To avoid paying expensive claims, they will put walls of paperwork between the claim and you, and sometimes have you climbing through levels of bureaucracy. Having an attorney on your side will help you avoid this stress as they understand how insurance companies work and will get through this bureaucracy for you.

Don't give up if your claim is denied the first time you file one. There is an appeal process to go through if insurance denies your claim the first time you file it. Your attorney will know how to interpret legal language used by your insurer and know how to appeal your case if they try to use 'experimental or not medically necessary' as reasons for denying you.

The insurance company may come up with absurd things in their language and use words to describe 'medically necessary' so they can deny your coverage. Your attorney and prosthetist can help you understand this language and get you through your claim with proper wording so the insurance will review your claim. There have been cases where the insurance company suddenly decides there are 'caps' to how much they will cover on a prosthesis and your attorney will be able to advise if this decision is legal or should be appealed.

If filing an appeal with your attorney and, you are sure you have exhausted all avenues available with the appeal process, you still have an option. Speak with your attorney about appealing to your state insurance commissioner. These commissioners work for you to make sure insurance companies give you the service that is required by your state and meet the intent and spirit of your state.

Keep all documentation throughout your entire process. From the day you find out from your physician that a prosthetic is required to replace one of your limbs, begin keeping all papers. If your case has to go in front of the state commissioner, you will need all documents relating to your needs and the denial from your insurance.

Winning a case that has gone through the commissioner means your insurance company will face penalties. The commissioner will also take steps to make sure your insurance company does not put any other amputee through this ordeal. The important piece to remember is if you are facing an insurance denial on your prosthetic; is have your paperwork in order and be gentle but firm when dealing with the company.

Through an appeal process, you can't give up or lose your temper. You should allow your attorney to handle as much of the contact as possible with the insurance company as they will understand how this process works and how to work with insurance personnel.

Insurance has been described as a complex puzzle with all the pieces looking the same. Your attorney has the experience to work through their paperwork process and understands their language. Contact an attorney if you, or someone you know, has been denied a claim for receiving a prosthesis.

Where to Find an Attorney to Appeal Prosthetic Limb Insurance Denial Near Me

If you have been denied insurance coverage for a prosthetic limb call Stop Health Insurance Denial at 310-695-5241. You will find expert help to work through the paperwork and get the help you need to file an appeal. We have the experience you need to fight the big insurance companies. Stop in and speak with a representative at 554 S. San Vicente Blvd Suite 160-L, Los Angeles, CA 90048, and discover how we can help you.