In recent years, an unsettling trend has emerged in the health insurance industry, with insurers increasingly questioning the medical necessity of prosthetic limbs. For individuals who rely on these devices to live fulfilling, active lives, this has become an obstacle that goes beyond financial stress it is a matter of functionality and independence.
Michael Adams, 51, a Colorado resident, experienced this challenge firsthand. Having lost his right leg to cancer 40 years ago, Adams has used prosthetic limbs throughout his life. His prosthetic leg, which includes a microprocessor-controlled knee, provides him with the stability necessary to perform daily activities like walking, climbing stairs, and skiing. This technology is essential for him, as the knee stiffens when it detects signs of a fall, helping to prevent injury.
When his prosthetic leg needed replacing in early 2023, Adams, who had recently switched to a new health plan on the Colorado health insurance marketplace, found himself in a difficult situation. His insurer denied coverage for the new leg, deeming the replacement unnecessary despite the fact that his doctor had prescribed the same prosthetic for years. The cost of the leg, including the specialized knee, was about $50,000 money Adams did not have to spare, especially when the decision had already been made by his doctor, who deemed the leg necessary for Adams’ well-being.
The situation highlights a disturbing reality in the insurance industry: while coverage for joint replacements like knees and hips is standard, coverage for prosthetic limbs particularly those equipped with advanced technology can be fraught with hurdles. In fact, prosthetic limb coverage varies significantly between insurers, and even the type of prosthetic approved can be limited.
Jeffrey Cain, a family physician and amputee, has been advocating for equitable coverage for prosthetics for years. Cain, who lost both of his legs in a plane accident, notes that insurance policies often favor replacements for body parts that are “covered with skin,” such as knee joint replacements, over prosthetics made from plastic or other materials. This creates a glaring disparity for amputees who need prosthetics to regain mobility and independence.
The problem is further compounded by the growing number of individuals who require prosthetics. In the United States, approximately 2.3 million people live with limb loss, with that number expected to double as people age and more individuals lose limbs due to conditions like diabetes or traumatic injury. Despite the high demand, fewer than half of people who experience limb loss are prescribed a prosthetic, and many insurance plans deny coverage, citing the device as “medically unnecessary.”
Legislative efforts have been made to address this issue. Colorado passed a law in 2000 that requires insurers to cover prosthetic limbs at a level comparable to Medicare, a law which has been followed by other states. However, these laws only apply to state-regulated health plans, and a significant number of people with private insurance are still excluded.
In addition to coverage challenges, the cost of prosthetics remains a major barrier. Even with insurance, patients often face steep out-of-pocket costs, with some prosthetics priced at tens of thousands of dollars. For many, this means relying on loans or payment plans to finance their devices. Unfortunately, for some individuals, the financial burden becomes too much to bear, leading to situations where necessary medical devices are repossessed.
For example, Adams ended up paying about $4,000 in coinsurance for his new leg after an appeal with his insurer. While he was fortunate enough to afford this payment, others like Leah Kaplan face greater challenges. Kaplan, born without a left hand, was denied coverage for a prosthetic hand that would cost over $46,000. The hand, which could enable her to perform everyday tasks, was deemed unnecessary by her insurer, despite the device’s clear potential to improve her quality of life.
The struggle for equitable prosthetic coverage is ongoing, but it shines a light on a broader issue within the health insurance system. As the demand for prosthetic limbs grows, so too does the need for insurance policies that truly prioritize the needs of individuals, ensuring that all patients regardless of their condition have access to the devices they require for independence, mobility, and a fulfilling life.
