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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Health Tips for Males Too
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝Articles are very informative and helpful. Maybe it’s me but things seem to lean more toward females. That being said don’t forget us males❞
Rest assured, we could never forget you! We try to make as much as possible of our content applicable to as many as possible of our readers, but of course not everything can be relevant for everyone.
This is, presumably, in response to our recent feature on menopausal health, because previous to that, our next-most-recent main feature that centred women’s health was a month ago—that was about breast cancer, and did have a section on breast cancer in men too. You might also enjoy the book we reviewed recently about prostate health, or our regular sponsor offering testosterone therapy. Please feel free to check out our articles on saw palmetto against male pattern baldness and BPH, as well as mental health issues that disproportionally affect men.
And of course, if you have specific questions/requests about men’s health (or any other health topic) we’re only ever an email away (or use the handy feedback widget, as you did to make this request)!
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The Worst Way to Wake Up (and What to Do Instead)
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Not everyone is naturally inclined to be a morning person, but there are things we can do to make things go more easily for our brains!
Cause for alarm?
Dr. Tracey Marks, psychiatrist, explains the impact of our first moments upon awakening, and what that can do to/for us in terms of sleep inertia (i.e. grogginess).
Sleep inertia is worse when waking from deep sleep—and notably, we don’t naturally wake directly from deep sleep unless we are externally aroused (e.g. by an alarm clock).
Dr. Marks suggests the use of more gradual alarms, including those with soft melodies, perhaps birdsong or other similarly gentle things (artificial sunlight alarms are also good), to ease our transition from sleeping to waking. It might take us a few minutes longer to be woken from sleep, but we’re not going to spend the next hour in a bleary-eyed stupor.
For more details on these things and more (including why not to hit “snooze”), enjoy:
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A Cold Shower A Day Keeps The Doctor Away?
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A Cold Shower A Day Keeps The Doctor Away?
This is Dutch extreme athlete Wim Hof, also known as “The Iceman”! He’s broken many world records mostly relating to the enduring the cold, for example:
- climbing Mount Kilimanjaro in shorts
- running a half-marathon above the Arctic Circle barefoot
- standing in a container completely covered with ice cubes for more than 112 minutes
You might not want to do yoga in your pyjamas on an iceberg, but you might like…
- better circulatory health
- reduced risk of stroke
- a boosted immune system
- healthier skin
- more energy and alertness
…and things like that. Wim Hof’s method is not just about extreme athletic achievements; most of what he does, the stuff that can benefit the rest of us, is much more prosaic.
The Wim Hof Method
For Wim Hof, three things are key:
- Breathing (See: Wim Hof Method Breathing Exercises)
- Commitment (See: How to Increase Willpower)
- Cold therapy (See: Benefits of Cold Therapy)
Today, we’re going to be focusing on the last one there.
What are the benefits of Cold Therapy?
Once upon a time, we didn’t have central heating, electric blankets, thermal underwear, and hot showers. In fact, once upon a time, we didn’t have houses or clothes. We used to be a lot more used to the elements! And while it’s all well and good to enjoy modern comforts, it has left our bodies lacking practice.
Practice at what? Most notably: vasodilation and vasoconstriction, in response to temperature changes. Either:
- vasodilation, because part of our body needs more blood to keep it warm and nourished, or
- vasoconstriction, because part of our body needs less blood running through it to get cooled down.
Switching between the two gives the blood vessels practice at doing it, and improves vascular muscle tone. If your body doesn’t get that practice, your blood vessels will be sluggish at making the change. This can cause circulation problems, which in turn have a big impact in many other areas of health, including:
- cardiovascular disease
- stroke risk
- mood instability
- nerve damage in extremities
On the flipside, if the blood vessels do get regular practice at dilating and constricting, you might enjoy lower risk of those things, and instead:
- improved immune response
- healthier skin
- better quality sleep
- more energy and alertness
- improved sexual performance/responsiveness
So, how to get that, without getting extreme?
As today’s title suggests, “a cold shower a day” is a great practice.
You don’t have to jump straight in, especially if you think your circulation and vascular responses might be a bit sluggish in the first instance. In fact, Wim Hof recommends:
- Week 1: Thirty seconds of cold water at the end of a warm shower each morning
- Week 2: One minute of cold water at the end of a warm shower each morning
- Week 3: A minute and a half of cold water at the end of a warm shower each morning
- Week 4: Two minutes of cold water at the end of a warm shower each morning
How cold is cold?
The benefits of cold exposure begin at around 16ºC / 60ºF, so in most places, water from the cold water mains is sufficiently cold.
As your body becomes more used to making the quick-change on a vascular level, the cold water will seem less shocking to your system. In other words, on day 30 it won’t hit you like it did on day one.
At that point, you can either continue with your two-minutes daily cold shower, and reap the benefits, or if you’re curious to push it further, that’s where ice baths come in!
Can anyone do it, or are any conditions contraindicated?
As ever, we’re a health and productivity newsletter, not doctors, let alone your doctors. Nothing here is medical advice. However, Wim Hof himself says:
❝Listen to your body, and never force the practices. We advise against doing Wim Hof Method if you are dealing with any of the following:
- Epilepsy
- High blood pressure
- Coronary heart disease
- A history of serious healthy issues like heart failure or stroke
- Pregnancy*
- Childhood*❞
*There is simply not enough science regarding the effects of cold exposure on people who are pregnant, or children. Obviously, we don’t expect this to be remedied anytime soon, because the study insitutions’ ethics boards would (rightly!) hold up the study.
As for the other conditions, and just generally if unsure, consult a doctor.
As you can see, this does mean that a limitation of Cold Therapy is that it appears to be far better as a preventative, since it helps guard against the very conditions that could otherwise become contraindications.
We haven’t peppered today’s main feature with study papers, partly because Wim Hof’s own website has kindly collated a collection of them (with links and summaries!) onto one page:
Further reading: The Science Behind The Wim Hof Method
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The Age-Proof Brain – by Dr. Marc Milstein
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Biological aging is not truly just one thing, but rather the amalgam of many things intersecting—and most of them are modifiable. The cells of your body neither know nor care how many times you have flown around the sun; they just respond to the stimuli they’re given.
Which is what fuels this book. The idea is to have a brain that is less-assailed by the things that would make it age, and more rejuvenated by the things that can make it biologically younger.
Dr. Milstein doesn’t neglect the rest of the body, and indeed notes the brain’s connections with the immune system, the heart, the gut, and more. But everything in this book is done with the brain in mind and its good health as the top priority outcome of all the things he advises.
On which note, yes, there is plenty of practical, implementable advice here. For a book that is consistently full of study paper citations, he does take care to make everything useful to the reader, and makes everything as easy as possible for the layperson along the way.
Bottom line: if you would like your brain to age less, this is an excellent, very evidence-based, guidebook.
Click here to check out The Age-Proof Brain, and age-proof your brain!
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The writing style is similar to The Comfort Book; it’s lots of small chapters, and all very easy-reading. Well, the subject matter is sometimes rather heavy, but the language is easy-reading! In other words, just the thing for when one is feeling easily overwhelmed, or not feeling up to reading a lot.
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Click here to check out Reasons To Stay Alive, and see through the highs and lows of life.
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100 Ways to Change Your Life – by Liz Moody
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In terms of format, these are presented in 100 tiny chapters, each approximately 2 pages long (obviously it depends on the edition, but you get the idea). Great to read in any of at least three ways:
- Cover-to-cover
- One per day for 100 days
- Look up what you need on an ad hoc basis
Bottom line: even if you already do half of these things, the other half will each compound your health happiness one-by-one as you add them. This is a very enjoyable and practical book!
Click here to check out 100 Ways to Change Your Life, and level-up yours!
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