In the complex landscape of health insurance, the coverage for prosthetic limbs stands out as a contentious issue, highlighting disparities and challenges faced by amputees. Michael Adams, a 51-year-old resident of Lafayette, Colorado, encountered this dilemma firsthand when his health insurance plan denied coverage for a much-needed prosthetic leg. Adams, who lost his right leg to cancer 40 years ago, had chosen a gold plan on the Colorado health insurance marketplace that specifically covered prosthetics, including the microprocessor-controlled knee he had relied on for years. This technology not only added stability but also helped prevent falls, significantly improving his quality of life.

However, when his leg required replacement after five years of daily use, his new health plan refused to authorize it. The insurer deemed the approximately $50,000 leg with the electronically controlled knee as not medically necessary, despite Colorado law stating that such determinations should be left to the patient’s doctor. Adams' doctor had prescribed a version of that leg for many years, starting when he had employer-sponsored coverage. "The electronic prosthetic knee is life-changing," Adams said. "Without it, it would be like going back to having a wooden leg like I did when I was a kid."

This situation is not unique. The amputee community often faces significant barriers in obtaining coverage for prosthetic devices, which they view as a form of discrimination. Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group, points out the stark contrast in coverage. "Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it," Cain said. He himself wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.

The disparity in coverage is particularly striking when compared to the coverage for joint replacement surgeries. 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 (AHRQ). The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, though health plans often negotiate lower rates.

The Amputee Coalition, which advocates for the rights of amputees, notes that while health plans generally provide coverage when a prosthetic is deemed medically necessary, the reality is that coverage varies widely. Ashlie White, chief strategy and programs officer at the Amputee Coalition, explains that even though basic prostheses may be included in a plan, "often insurance companies will put caps on the devices and restrictions on the types of devices approved."

An estimated 2.3 million people are living with limb loss in the U.S., according to an analysis by Avalere, a health care consulting company. This number is expected to double in the coming years as the population ages and more people lose limbs to diabetes, trauma, and other medical problems. Fewer than half of people with limb loss have been prescribed a prosthesis, according to a report by the AHRQ.

Plans may deny coverage for prosthetic limbs by claiming they aren’t medically necessary or are experimental devices, even though technologies like microprocessor-controlled knees have been in use for decades. Cain was instrumental in getting passed a 2000 Colorado law that requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20% coinsurance payment. Since that measure was enacted, about half of states have passed “insurance fairness” laws that require prosthetic coverage on par with other covered medical services in a plan or laws that require coverage of prostheses that enable people to do sports. However, these laws apply only to plans regulated by the state. Over half of people with private coverage are in plans not governed by state law.

The Medicare program’s 80% coverage of prosthetic limbs mirrors its coverage for other services. Still, an October report by the Government Accountability Office found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years. Cost is a significant factor for many people. "No matter your coverage, most people have to pay something on that device," White said. As a result, "many people will be on a payment plan for their device," she said. Some may take out loans. The federal Consumer Financial Protection Bureau has proposed a rule that would prohibit lenders from repossessing medical devices such as wheelchairs and prosthetic limbs if people can’t repay their loans. "It is a replacement limb," said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prostheses. Repossession is "literally a punishment to the individual."

Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his portion of the insurer’s negotiated rate for the knee and foot portion of the leg but did not include the costly part that fits around his stump, which didn’t need replacing. The insurer approved the prosthetic leg on appeal, claiming it had made an administrative error, Adams said. "We’re fortunate that we’re able to afford that 20%," said Adams, who is a self-employed leadership consultant.

Leah Kaplan, 32, does not have the same financial flexibility. Born without a left hand, she did not have a prosthetic limb until a few years ago. Growing up, "I didn’t want more reasons to be stared at," said Kaplan, explaining her decision not to use a prosthesis. A few years ago, the cycling enthusiast got a prosthetic hand specially designed for use with her bike. That device was covered under the health plan she has through her county government job in Spokane, Washington, helping developmentally disabled people transition from school to work. But when she tried to get approval for a prosthetic hand to use for everyday activities, her health plan turned her down. The myoelectric hand she requested would respond to electrical impulses in her arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she said she can’t afford. Working with her doctor, she has appealed the decision to her insurer and been denied three times. Kaplan said she’s still not sure exactly what the rationale is, except that the insurer has questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent review organization certified by the state insurance commissioner’s office. A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic has ordered the hand and made the customized socket that will fit around the end of her arm. But until insurance coverage is sorted out, she can’t use it. At this point, she feels defeated. “I’ve been waiting for this for so long,” Kaplan said.

Conclusion: Advocating for Fair and Comprehensive Coverage

The struggle for fair and comprehensive coverage of prosthetic limbs is a battle for equity and access to essential healthcare. As the number of individuals living with limb loss is expected to increase, it is imperative that insurance policies adapt to meet their needs. The current patchwork of state laws and varying interpretations of medical necessity create a confusing and often frustrating landscape for amputees seeking prosthetic devices.

Advocacy groups like the Amputee Coalition continue to push for legislation that ensures prosthetic coverage is on par with other medical services and that insurance companies are held accountable for their decisions. The personal stories of individuals like Michael Adams and Leah Kaplan underscore the human impact of these policies and the importance of a system that values functionality and quality of life.

In the meantime, individuals and families affected by limb loss must navigate a complex system, often facing financial hardships and delays in accessing the devices that can significantly improve their daily lives. The journey towards fair prosthetic limb coverage is ongoing, and it requires the collective effort of policymakers, healthcare providers, and the community to ensure that no one is left behind in the pursuit of a full and active life.