Health insurers limit coverage of prosthetic limbs, questioning their medical necessity

[BumRushDaShow]

Source: ABC News

January 6, 2025, 5:20 PM


When Michael Adams was researching health insurance options in 2023, he had one very specific requirement: coverage for prosthetic limbs. Adams, 51, lost his right leg to cancer 40 years ago, and he has worn out more legs than he can count. He picked a gold plan on the Colorado health insurance marketplace that covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. That function adds stability and helps prevent falls.

But when his leg needed replacing last January after about five years of everyday use, his new marketplace health plan wouldn't authorize it. The roughly $50,000 leg with the electronically controlled knee wasn't medically necessary, the insurer said, even though Colorado law leaves that determination up to the patient's doctor, and his has prescribed a version of that leg for many years, starting when he had employer-sponsored coverage.

"The electronic prosthetic knee is life-changing," said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, "it would be like going back to having a wooden leg like I did when I was a kid." The microprocessor in the knee responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling. People who need surgery to replace a joint typically don't encounter similar coverage roadblocks.

In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, though health plans often negotiate lower rates. To people in the amputee community, the coverage disparity amounts to discrimination.

Read more: https://abcnews.go.com/Health/health-insurers-limit-coverage-prosthetic-limbs-questioning-medical/story?id=117393625

[hlthe2b]

1. And these CEOs wonder what precipitated the tragic murder of one of their own...

I detest them too, albeit I could never condone that specific crime.

[riversedge]

10. +

[Bengus81]

13. I'll BUMP the hell out of that post...........

[AllyCat]

2. Every last CEO running a company that takes

$ from people for care and then don’t pay out is a thief at best and a murderer at worst.

Health insurance needs to die as an industry. The CEOs are to blame for allowing this crime to continue.

Luigi speaks for many of us.

Too bad the source here is Nazi Broadcasting Company and not credible.

[OldBaldy1701E]

6. You want it to go away?

Remove the mandatory laws about it. The fact that we have to have it is what keeps it going. You remove the fact that the law requires it and their massive profits would start to drop like a stone. That would remove a lot of their power and influence.

That is assuming lawmakers don't get railroaded into making it illegal to try anything that might upset the vaunted insurance business. Which I would not put past any of them.

[Voltaire2]

9. Wtf?

This idiotic talking point is from the original ACA rollout that included a very small fee for people who opted out of coverage. The ‘mandate’ was never compulsory, and the rightwing outrage was entirely manufactured.

You go right ahead and not have any health insurance. Good luck!

[OldBaldy1701E]

30. I don't have health insurance.

I have a joke that claims to be health insurance. And, even that will be gone soon enough due to inability to pay. Hell, we may be homeless in a few months the way things are going. There is no help out there. I have looked.

Anyway, I was responding to the person who mentioned that they wanted to know how to make it 'go away'. I offered a suggestion. If you do not approve of it, whatever. However, I was referring to all insurance. Like the kind you have to have to get a drivers license. Or the kind you have to have to run a business. Or the kind you have to have to build a house. There are plenty of instances where insurance is required by law. Since that is the case, one will never be able to get rid of it without getting rid of the 'safety net' that mandatory compulsion affords.

I hope that helps.

[mamacita75]

32. Insurance

IMO is all a racket. A type of organized crime.

[OldBaldy1701E]

37. In many ways, it is exactly that. And, we let it keep on keeping on. (n/t)

[AllyCat]

24. You want it to go away?

Eat the phucking rich.

[OldBaldy1701E]

29. Well, my suggestion was less messy...

But, yours works too.

[AllyCat]

36. Mine makes a greater impression.

I also disagreed with the mandate to buy a private product. But making it go away means those of us who pay have to pay for everyone who doesn’t.

Universal health care is the way, but eating the rich will solve our looming hunger issues.

[Joinfortmill]

3. The greed is out of control.

There's going to be a seismic change in the U. S. A. It's already begun with the mass exodus from MSM to independent outlets. It's gonna be a rough ride until we get there, but we will get there. RESIST.

[bmichaelh]

4. Medical Necessary

Insurers abuse the system by denying coverage by saying its not medically necessary.

[lastlib]

5. Bean counters practicing medicine...... Eff 'em with a cactus.

I have had a SEEETHING hatred of for-profit medical insurance ever since 1987, when they decided that my sister's life wasn't "medically necessary," and cost them too much profit.

- - - - - - - - - - - - - - -

Make that cactus a saguaro!

[ColinC]

7. Thus confirming health insurance does actually cost an arm and a leg

[Orrex]

8. The obvious answer is to rip the limbs off of a few executives

Two per executive should be a good start.

[Prairie Gates]

19. Mario is coming...

[Magoo48]

11. Universal healthcare for all. Eliminate health insurance permanently. Internal and external review of program mechanics.

[Think. Again.]

27. ⬆⬆⬆THIS⬆⬆⬆

[2naSalit]

12. The cruelty is the point.

[Bengus81]

14. Yep sadly...as they laugh and clink their drink glasses together in a toast

of how many BILLIONS of $$$$ they saved the Corporation on now denying limbs. Sick,sick FUCKS........

[milestogo]

15. Years ago I had a friend whose daughter was born without an arm.

The insurance company didn't want to pay for a prosthetic arm because- she didn't lose an arm, she never had one to begin with. Not their problem.

[AllyCat]

25. OMG.

[Ilsa]

28. So, they wouldn't even consider the child's

emotional and social development? How corrupt, coldhearted, vicious. Fuck them.

[milestogo]

31. Add to that - because its a growing child

she's going to need one prosthetic arm after another. So the need is never going to end. I guess its the ultimate pre-existing condition.

[Attilatheblond]

16. Business model is now openly " just pay us and shut the F up"

[sakabatou]

17. Then the people who made this new policy should have a limb removed.

Maybe then they'll see that they're needed.

[Prairie Gates]

18. Prosthetic limbs will hereinafter be called Vanity Limbs

Amen.

[mamacita75]

33. Exactly

what they need to be called.
Good one.

[generalbetrayus]

20. If he hasn't already done so, Michael Adams needs to reach out to Colorado's Second Congressional District

representative Democrat Joe Neguse, who lives in Lafayette. I'm pretty sure he will get a sympathetic hearing.

[Pachamama]

21. Maybe if they lost limbs they would understand the need and importance of prosthetics?

[Vinca]

22. Insurer: "As long as you can hop on one leg, sorry. Request denied."

[JoseBalow]

23. It's just a flesh wound

[Jilly_in_VA]

26. SERIOUSLY?

Assholes.

[IcyPeas]

34. Where's the investigation? CEOs should be dragged in and made to answer.

This is criminal .

[buzzycrumbhunger]

35. My son lost a leg at 17

Rampaging Strep infection that took six surgeries in seven days before they finally took the whole thing to get ahead of it.

Thanks to the Shriners, we then spent six weeks in their Tampa hospital (a parent is allowed to stay in a motel-type room for free!) getting rehab and fit for a prosthetic. They eventually made a second leg and provided a cool wheelchair because they knew once he turned 18, we’d be fucked—and we were.

He outgrew his prosthesis in his mid 20s and it wasn’t until he was over 40 that he met someone at work who put him in touch with a clinic that did a few freebies. He now has a new, improved leg (nothing terribly fancy, but a better knee than his first ones) at no cost. All these years, he’s tried to apply for help from SSI, etc. and no one would help him. He was able to get around, feed himself, and go to school, so would never qualify for aid. It took a random encounter to get free help.

It’s disgusting. The so-called healthcare industry serves no real purpose but to skim money off people for providing as few services as possible in order to reward stockholders.

Just another reason these arseholes should fear the coming Luigi imitators. It’s beyond time for healthcare for ALL.