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

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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