Health Insurers Limit Coverage of Prosthetic Limbs, Questioning Their Medical Necessity
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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.
“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,” said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.
AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition. Even though coverage for 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,” White said.
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. That number is expected to as much as double in coming years as people age and a growing number 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 microprocessor-controlled knees like Adams’ 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. But 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 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 doesn’t have that 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, 32, of 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.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
This article first appeared on KFF Health News and is republished here under a Creative Commons license.
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Ruminating vs Processing
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When it comes to traumatic experiences, there are two common pieces of advice for being able to move forwards functionally:
- Process whatever thoughts and feelings you need to process
- Do not ruminate
The latter can seem, at first glance, a lot like the former. So, how to tell them apart, and how to do one without the other?
Getting tense
One major difference between the two is the tense in which our mental activity takes place:
- processing starts with the traumatic event (or perhaps even the events leading up to the traumatic event), analyses what happened and if possible why, and then asks the question “ok, what now?” and begins work on laying out a path for the future.
- rumination starts with the traumatic event (or perhaps even the events leading up to the traumatic event), analyses what happened and if why, oh why oh why, “I was such an idiot, if only I had…” and gets trapped in a fairly tight (and destructive*) cycle of blame and shame/anger, never straying far from the events in question.
*this may be directly self-destructive, but it can also sometimes be only indirectly self-destructive, for example if the blame and anger is consciously placed with someone else.
This idea fits in, by the way, with Dr. Elisabeth Kübler-Ross’s “five stages of grief” model; rumination here represents the stages “bargaining”, “despair”, and “anger”, while emotional processing here represents the stage “acceptance”. Thus, it may be that rumination does have a place in the overall process—just don’t get stuck there!
For more on healthily processing grief specifically:
What Grief Does To The Body (And How To Manage It)
Grief, by the way, can be about more than the loss of a loved one; a very similar process can play out with many other kinds of unwanted life changes too.
What are the results?
Another way to tell them apart is to look at the results of each. If you come out of a long rumination session feeling worse than when you started, it’s highly unlikely that you just stopped too soon and were on the verge of some great breakthrough. It’s possible! But not likely.
- Processing may be uncomfortable at first, and if it’s something you’ve ignored for a long time, that could be very uncomfortable at first, but there should quite soon be some “light at the end of the tunnel”. Perhaps not even because a solution seems near, but because your mind and body recognize “aha, we are doing something about it now, and thus may find a better way forward”.
- Rumination tends to intensify and prolong uncomfortable emotions, increases stress and anxiety, and likely disrupts sleep. At best, it may serve as a tipping point to seek therapy or even just recognize “I should figure out a way to deal with this, because this isn’t doing me any good”. At worst, it may serve as a tipping point to depression, and/or substance abuse, and/or suicidality.
See also: How To Stay Alive (When You Really Don’t Want To) ← which also has a link back to our article on managing depression, by the way!
Did you choose it, really?
A third way to tell them apart is the level of conscious decision that went into doing it.
- Processing is almost always something that one decides “ok, let’s figure this out”, and sits down to figure it out.
- Rumination tends to be about as voluntary as social media doomscrolling. Technically we may have decided to begin it (we also might not have made any conscious decision, and just acted on impulse), but let’s face it, our hands weren’t at the wheel for long, at all.
A good way to make sure that it is a conscious process, is to schedule time for it in advance, and then do it only during that time. If thoughts about it come up at other times, tell yourself “no, leave that for later”, and then deal with it when (and only when) the planned timeslot arrives.
It’s up to you and your schedule what time you pick, but if you’re unsure, consider an hour in the early evening. That means that the business of the day is behind you, but it’s also not right before bed, so you should have some decompression time as a buffer. So for example, perhaps after dinner you might set a timer* for an hour, and sit down to journal, brainstorm, or just plain think, about the matter that needs processing.
*electronic timers can be quite jarring, and may distract you while waiting for the beeps. So, consider investing in a relaxing sand timer like this one instead.
Is there any way to make rumination less bad?
As we mentioned up top, there’s a case to be made for “rumination is an early part of the process that gets us where we need to go, and may not be skippable, or may not be advisable to skip”.
So, if you are going to ruminate, then firstly, we recommend again bordering it timewise (with a timer as above) and having a plan to pull yourself out when you’re done rather than getting stuck there (such as: The Off-Button For Your Brain: How To Stop Negative Thought Spirals).
And secondly, you might want to consider the following technique, which allows one to let one’s brain know that the thing we’re thinking about / imagining is now to be filed away safely; not lost or erased, but sent to the same place that nightmares go after we wake up:
A Surprisingly Powerful Tool: Eye Movement Desensitization & Reprocessing (EMDR)
What if I actually do want to forget?
That’s not usually recommendable; consider talking it through with a therapist first. However, for your interest, there is a way:
The Dark Side Of Memory (And How To Forget)
Take care!
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Foods That Cause You to Lose Weight – by Dr. Neal Barnard
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We previously reviewed Dr. Barnard’s “The Power Foods Diet”, and this time his work is about weight loss.
This time there are more recipes (which take up most of the book, so this one could be reasonably described as a cookbook), but not until after nearly a hundred pages of concepts, principles, and tips.
The recipes themselves are again very respectable, even if some may be a little redundant (e.g. the double-page recipe for blueberry muffins is followed by a double-page recipe for banana and date muffins, instead of just saying “or substitute this”—things like that) and run the gamut from salad dressings to hearty main meals.
A strength of the book is that it’s about what you eat, not how much of it you eat, so if you love eating (which is a very healthy trait to have in general), then you’ll enjoy that aspect.
Bottom line: if you’d like to eat more and weigh less, then this is a top-tier book for you.
Click here to check out “Foods That Cause You To Lose Weight”, and enjoy eating!
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Lucid Dreaming: How To Do It, & Why
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Lucid Dreaming: Methods & Uses
We’ve written about dreaming more generally before:
Today we’re going to be talking more about a subject we’ve only touched on previously: lucid dreaming
What it is: lucid dreaming is the practice of being mentally awake while dreaming, with awareness that it is a dream, and control over the dream.
Why is it useful? Beyond simply being fun, it can banish nightmares, it can improve one’s relationship with sleep (always something to look forward to, and sleep doesn’t feel like a waste of time at all!), and it can allow for exploring a lot of things that can’t easily be explored otherwise—which can be quite therapeutic.
How to do it
There are various ways to induce lucid dreaming, but the most common and “entry-level” method is called Mnemonic-Induced Lucid Dreaming (MILD).
MILD involves having some means of remembering what one has forgotten, i.e., that one is dreaming. To break it down further, first we’ll need to learn how to perform a reality check. Again, there are many of these, but one of the simplest is to ask yourself:
How did I get here?
- If you can retrace your steps with relative ease and the story of how you got here does not sound too much like a dream sequence, you are probably not dreaming.
- If you are dreaming, however, chances are that nothing actually led to where you are now; you just appeared here.
Other reality checks include checking whether books, clocks, and/or lightswitches work as they should—all are notorious for often being broken in dreams; books have gibberish or missing or repeated text; clocks do not tell the correct time and often do not even tell a time that could be real (e.g: 07:72), and lightswitches may turn a light on/off without actually changing the level of illumination in the room.
Now, a reality check is only useful if you actually perform it, so this is where MILD comes in.
You need to make a habit of doing a reality check frequently. Whenever you remember, it’s a good time to do a reality check, but you should also try tying it to something. Many people use a red light, because then they can also use a timed red light during the night to subconsciously cue them that they are dreaming. But it could be as simple as “whenever I go to the bathroom, I do a reality check”.
With this in mind, a fun method that has extra benefits is to try to use a magical power, such as psychokinesis. If (while fully awake) whenever you go to pick up some object you imagine it just wooshing magically to meet your hand halfway, then at some point you’ll instinctively do that while dreaming, and it’ll stand a good chance of working—and thus cluing you in that you are dreaming.
How to stay lucid
When you awaken within a dream (i.e. become lucid), there’s a good chance of one of two things happening quickly:
- you forget again
- you wake up
So when you realize you are dreaming, do two things at once:
- verbally repeat to yourself “I am dreaming now”. This will help stretch your awareness from one second to the next.
- look at your hands, and touch things, especially the floor and/or walls. This will help to ground you within the dream.
Things to do while lucid
Flying is a good fun entry-level activity; it’s very common to initially find it difficult though, and only be able to lift up very slightly before gently falling down, or things like that. A good tip is: instead of trying to move yourself, you stay still and move the dream around you, as though you are rotating a 3D model (because guess what: you are).
Confronting your nightmares and/or general fears is a good thing for many. Think, while you’re still awake during the day, about what you would do about the source/trigger of your fear if you had magical powers. Whatever you choose, keep it consistent for now, because this is about habit-forming.
Example: let’s say there’s a person from your past who appears in your nightmares. Let’s say your chosen magic would be “I would cause the ground to open up, swallow them, and close again behind them”. Vividly imagine that whenever they come to mind while you are awake, and when you encounter them next in a nightmare, you’ll remember to do exactly that, and it’ll work.
Learning about your own subconscious is a more advanced activity, but once you’re used to lucid dreaming, you can remember that everything in there is an internal projection of your own mind, so you can literally talk to parts of your subconscious, including past versions of yourself, or singular parts of your greater-whole personality, as per IFS:
Take Care Of Your “Unwanted” Parts Too!
Want to know more?
You might like to read:
Enjoy!
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When can my baby drink cow’s milk? It’s sooner than you think
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Parents are often faced with well-meaning opinions and conflicting advice about what to feed their babies.
The latest guidance from the World Health Organization (WHO) recommends formula-fed babies can switch to cow’s milk from six months. Australian advice says parents should wait until 12 months. No wonder some parents, and the health professionals who advise them, are confused.
So what do parents need to know about the latest advice? And when is cow’s milk an option?
What’s the updated advice?
Last year, the WHO updated its global feeding guideline for children under two years old. This included recommending babies who are partially or totally formula fed can have whole animal milks (for example, full-fat cow’s milk) from six months.
This recommendation was made after a systematic review of research by WHO comparing the growth, health and development of babies fed infant formula from six months of age with those fed pasteurised or boiled animal milks.
The review found no evidence the growth and development of babies who were fed infant formula was any better than that of babies fed whole, fresh animal milks.
The review did find an increase in iron deficiency anaemia in babies fed fresh animal milk. However, WHO noted this could be prevented by giving babies iron-rich solid foods daily from six months.
On the strength of the available evidence, the WHO recommended babies fed infant formula, alone or in addition to breastmilk, can be fed animal milk or infant formula from six months of age.
The WHO said that animal milks fed to infants could include pasteurised full-fat fresh milk, reconstituted evaporated milk, fermented milk or yoghurt. But this should not include flavoured or sweetened milk, condensed milk or skim milk.
If you’re choosing cow’s milk for your baby, make sure it’s whole milk rather than skim milk. Mr Adi/Shutterstock Why is this controversial?
Australian government guidelines recommend “cow’s milk should not be given as the main drink to infants under 12 months”. This seems to conflict with the updated WHO advice. However, WHO’s advice is targeted at governments and health authorities rather than directly at parents.
The Australian dietary guidelines are under review and the latest WHO advice is expected to inform that process.
OK, so how about iron?
Iron is an essential nutrient for everyone but it is particularly important for babies as it is vital for growth and brain development. Babies’ bodies usually store enough iron during the final few weeks of pregnancy to last until they are at least six months of age. However, if babies are born early (prematurely), if their umbilical cords are clamped too quickly or their mothers are anaemic during pregnancy, their iron stores may be reduced.
Cow’s milk is not a good source of iron. Most infant formula is made from cow’s milk and so has iron added. Breastmilk is also low in iron but much more of the iron in breastmilk is taken up by babies’ bodies than iron in cow’s milk.
Babies should not rely on milk (including infant formula) to supply iron after six months. So the latest WHO advice emphasises the importance of giving babies iron-rich solid foods from this age. These foods include:
- meat
- eggs
- vegetables, including beans and green leafy vegetables
- pulses, including lentils
- ground seeds and nuts (such as peanut or other nut butters, but with no added salt or sugar).
You may have heard that giving babies whole cow’s milk can cause allergies. In fact, whole cow’s milk is no more likely to cause allergies than infant formula based on cow’s milk.
If you’re introducing cow’s milk at six months, offer iron-rich foods too, such as meat or lentils. pamuk/Shutterstock What are my options?
The latest WHO recommendation that formula-fed babies can switch to cow’s milk from six months could save you money. Infant formula can cost more than five times more than fresh milk (A$2.25-$8.30 a litre versus $1.50 a litre).
For families who continue to use infant formula, it may be reassuring to know that if infant formula becomes hard to get due to a natural disaster or some other supply chain disruption fresh cow’s milk is fine to use from six months.
It is also important to know what has not changed in the latest feeding advice. WHO still recommends infants have only breastmilk for their first six months and then continue breastfeeding for up to two years or more. It is also still the case that infants under six months who are not breastfed or who need extra milk should be fed infant formula. Toddler formula for children over 12 months is not recommended.
All infant formula available in Australia must meet the same standard for nutritional composition and food safety. So, the cheapest infant formula is just as good as the most expensive.
What’s the take-home message?
The bottom line is your baby can safely switch from infant formula to fresh, full-fat cow’s milk from six months as part of a healthy diet with iron-rich foods. Likewise, cow’s milk can also be used to supplement or replace breastfeeding from six months, again alongside iron-rich foods.
If you have questions about introducing solids your GP, child health nurse or dietitian can help. If you need support with breastfeeding or starting solids you can call the National Breastfeeding Helpline (1800 686 268) or a lactation consultant.
Karleen Gribble, Adjunct Associate Professor, School of Nursing and Midwifery, Western Sydney University; Naomi Hull, PhD candidate, food security for infants and young children, University of Sydney, and Nina Jane Chad, Research Fellow, University of Sydney School of Public Health, University of Sydney
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Clean – by Dr. James Hamblin
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Our skin is our largest organ, and it’s easy to forget that, and how much it does for us. All things considered, it’s good to take good care of it! But what if we sometimes take too much “care” of it?
Dr. James Hamblin, a medical doctor-turned-writer, has explored this a lot both personally and in research. Through such, he has come to the conclusion there’s definitely a “sweet spot” of personal hygiene:
- Too little, and the Bubonic plague sweeps through Europe, or other plagues sweep through other places when European invaders came.
- Too much, and we strip our skin of one of its greatest qualities: the ability to protect us.
Dr. Hamblin asks (and answers) such questions as:
- What is good hygiene, and what is neurotically doing ourselves multiple levels of harm because advertising companies shamed us into doing so?
- Is it good or bad to use a series of products, each to undo the problem caused by the previous?
- What the difference between a 5-step skincare routine, and a series of gratuitous iatrogenic damage?
- Which products clean us most helpfully, and which clean us most harmfully?
- How often should we bathe/shower, really?
If the book has a weak point, it’s that it’s written mostly with his body in mind. That makes a difference when it comes to hairwashing, for example. He’s a white guy with short hair. If you’re black and/or have long hair, for example, your haircare needs will be quite different. Similarly, many women engage in shaving/depilation in places that most men don’t, and the consequences of that choice (and implications for any extra washing needs/harms) aren’t covered.
Bottom line: notwithstanding the aforementioned blind-spots, this book will help readers reduce the amount of harm we are doing to our bodies with our washing routines, without sacrificing actual hygiene.
Click here to check out Clean and help your skin to help you!
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Freekeh Tomato Feast
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Fiber-dense freekeh stars in this traditional Palestinian dish, and the whole recipe is very gut-healthy, not to mention delicious and filling, as well as boasting generous amounts of lycopene and other phytonutrients:
You will need
- 1 cup dried freekeh (if avoiding gluten, substitute a gluten-free grain, or pseudograin such as buckwheat; if making such a substitution, then also add 1 tbsp nutritional yeast—for the flavor as well as the nutrients)
- 1 medium onion, thinly sliced
- 1 2oz can anchovies (if vegan/vegetarian, substitute 1 can kimchi)
- 1 14oz can cherry tomatoes
- 1 cup halved cherry tomatoes, fresh
- ½ cup black olives, pitted
- 1 5oz jar roasted peppers, chopped
- ½ bulb garlic, thinly sliced
- 2 tsp black pepper
- 1 tsp chili flakes
- 1 sprig fresh thyme
- Extra virgin olive oil
Method
(we suggest you read everything at least once before doing anything)
1) Place a heavy-based (cast iron, if you have it) sauté pan over a medium heat. Add some olive oil, then the onion, stirring for about 5 minutes.
2) Add the anchovies, herbs and spices (including the garlic), and stir well to combine. The anchovies will probably soon melt into the onion; that’s fine.
3) Add the canned tomatoes (but not the fresh), followed by the freekeh, stirring well again to combine.
4) Add 2 cups boiling water, and simmer with the lid on for about 40 minutes. Stir occasionally and check the water isn’t getting too low; top it up if it’s getting dry and the freekeh isn’t tender yet.
5) Add the fresh chopped cherry tomatoes and the chopped peppers from the jar, as well as the olives. Stir for just another 2 minutes, enough to let the latest ingredients warm through.
6) Serve, adding a garnish if you wish:
Enjoy!
Want to learn more?
For those interested in some of the science of what we have going on today:
- Why You’re Probably Not Getting Enough Fiber (And How To Fix It)
- Eat More (Of This) For Lower Blood Pressure
- Making Friends With Your Gut (You Can Thank Us Later)
- Lycopene’s Benefits For The Gut, Heart, Brain, & More
- Our Top 5 Spices: How Much Is Enough For Benefits?
Take care!
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