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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The Worst Cookware Lurking In Your Kitchen (Toxicologist Explains)
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Dr. Yvonne Burkart gives us a rundown of the worst offenders, and what to use instead:
Hot mess
The very worst offender is non-stick cookware, the kind with materials such as Teflon. These are the most toxic, due to PFAS chemicals.
Non-stick pans release toxic gases, leach chemicals into food, and release microplastic particles, which can accumulate in the body.
One that a lot of people don’t think about, in that category, is the humble air-fryer, which often as not has a non-stick cooking “basket”. These she describes as highly toxic, as they combine plastic, non-stick coatings, and high heat, which can release fumes and other potentially dangerous chemicals into the air and food.
You may be wondering: how bad is it? And the answer is, quite bad. PFAS chemicals are linked to infertility, hypertension in pregnancy, developmental issues in children, cancer, weakened immune systems, hormonal disruption, obesity, and intestinal inflammation.
Dr. Burkart’s top picks for doing better:
- Pure ceramic cookware: top choice for safety, particularly brands like Xtrema, which are tested for heavy metal leaching.
- Carbon steel & cast iron: durable and safe; can leach iron in acidic foods (for most people, this is a plus, but some may need to be aware of it)
- Stainless steel: lightweight and affordable but can leach nickel and chromium in acidic foods at high temperatures. Use only if nothing better is available.
And specifically as alternatives to air-fryers: glass convection ovens or stainless steel ovens are safer than conventional air fryers. The old “combination oven” can often be a good choice here.
For more on all of these, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
- PFAS Exposure & Cancer: The Numbers Are High
- It’s Not Fantastic To Be Plastic ← for the closely related topic of microplastics and nanoplastics
Take care!
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How to Fall Back Asleep After Waking Up in the Middle of the Night
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Dr. Michael Bruce, the Sleep Doctor, addresses a common concern: waking up in the middle of the night and struggling to fall back asleep.
Understanding the Wake-Up
Firstly, why are we waking up during the night?
Waking up between 2 AM and 3 AM is said to be normal, and linked to your core body temperature. As your body core temperature drops, to trigger melatonin release, and then rises again, you get into a lighter stage of sleep. This lighter stage of sleep makes you more prone to waking up.
Note, there are also some medical conditions (such as sleep apnea) that can cause you to wake up during the night.
But, what can we do about it? Aside from constantly shifting sleeping position (Should I be sleeping on my back? On my left? Right?)
Avoid the Clock
The first step is to resist the urge to check the time. It’s easy to be tempted to have a look at the clock, however, doing so can increase anxiety, making it harder to fall back asleep. As Dr. Bruce says, sleep is like love—the less you chase it, the more it comes.
It may be useful to point your alarm clock (if you still have one of those) the opposite direction to your bed.
Embracing Non-Sleep Deep Rest (NSDR)
Whilst this may not help you fall back asleep, it’s worth pointing out that just lying quietly in the dark without moving still offers rejuvenation. This revujenating stage is called Non-Sleep Deep Rest (otherwise known as NSDR)
If you’re not familiar with NSDR, check out our overview of Andrew Huberman’s opinions on NSDR here.
So, you can reassure yourself that whilst you may not be asleep, you are still resting.
Keep Your Heart Rate Down
To fall back asleep, it’s best if your heart rate is below 60 bpm. So, Dr. Bruce advises avoiding void getting up unnecessarily, as moving around can elevate your heart rate.
On a similar vain, he introduces the 4-7-8 breathing technique, which is designed to lower your heart rate. The technique is simple:
- Breathe in for 4 seconds.
- Hold for 7 seconds.
- Exhale for 8 seconds.
Repeat this cycle gently to calm your body and mind.
As per any of our Video Breakdowns, we only try to capture the most important pieces of information in text; the rest can be garnered from the video itself:
Wishing you a thorough night’s rest!
Do you know any other good videos on sleep? Send them to us via email!
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The 4 Bad Habits That Cause The Most Falls While Walking
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The risk of falling becomes greater (both in probability and in severity of consequences) as we get older. But, many people who do fall do so for the same reasons, some of which are avoidable. Dr. Doug Weiss has advice based on extensive second-hand experience:
Best foot forward!
If any of these prompt a “surely nobody does that” response, then, good for you to not have that habit, but Dr. Weiss has seen many patients who thusly erred. And if any of these do describe how you walk, then well, you’re not alone—time to fix it, though!
- Walking with Stiff Legs: walking with a hyperextended (straight) knee instead of a slight bend (5-15°) makes it harder to adjust balance, increasing the risk of falls. This can also put extra pressure on the joints, potentially leading to osteoarthritis.
- Crossing Legs While Turning: turning by crossing one leg over the other is a common cause of falls, particularly in the elderly. To avoid this, when turning step first with the foot that is on the side you are going to go. If you have the bad habit, this may feel strange at first, but you will soon adapt.
- Looking Down While Walking: focusing only on the ground directly in front of you can cause you to miss obstacles ahead, leading to falls. Instead, practice “scanning”, alternating between looking down at the ground and looking up to maintain awareness of your surroundings.
- Shuffling Instead of Tandem Walking: shuffling with feet far apart, rather than walking with one foot in front of the other, reduces balance and increases the risk of tripping. Tandem walking, where one foot is placed directly in front of the other, is the safer and more balanced way to walk.
It also helps disguise your numbers.
For more details on all of these, plus visual demonstrations, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
Fall Special (How To Not Fall, And How To Minimize Injury If You Do) ← this never seems like an urgent thing to learn, but trust us, it’s more fun to read it now, than from your hospital bed later
Take care!
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The Secret to Mental Health – by George Pransky
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This book (and its author) have a sizeable popular following, so it definitely can be said that it has been well-received by many people. The premise in this book is that there is fundamentally nothing wrong with anybody’s brain, and rather everything can be broken down into:
- Mind (the energy and intelligence that animates all life)
- Consciousness (the capacity to be aware of one’s life and experiences)
- Thought (the ability to think, allowing individuals to create their personal experience of reality)
The author explains, over the course of 145 pages, that where anyone with any perceived mental health issue is going wrong is by either lacking self-awareness (Consciousness) or erring by creating an undesirable personal experience of reality (Thought).
In terms of the science of this, frequent references are made to “there is evidence that shows”, “new discoveries about mental health suggest…”, etc, but this claimed evidence is never actually presented, just alluded to. Where many books would have a bibliography, this one has simply a collection of what the author has titled “interesting case studies, conversations, papers, and discussions” (there are no actual case studies or papers; it is just a collection of anecdotes).
The style is… Honestly, in this reviewer’s opinion, barely readable. But, apparently lots of people love it, so your mileage may vary.
We don’t usually delve too far into claimed credentials, but because of the interesting writing style and the bold claims without evidence, we were curious as to where this PhD came from, and apparently it came from a now-shut-down diploma mill that was described by the court as “a complete scam”.
Bottom line: we can’t recommend this one, but we read it so that you don’t have to, and we hope that publishing this review will help reassure you that when we do recommend a book, we mean it!
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The Neuroscience of You – by Dr. Chantel Prat
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The insides of people are rarely so standardized as one finds in a medical textbook, and that’s just as true of the brain as it is of any other organ—and often more so.
Our brains all look quite different from each other’s. Of course there are similarities; a wobbly mass of white and grey matter with tiny blood vessels running through. The constituent parts are (usually!) all present and correct. But… what is “correct”?
Dr. Chantel Prat takes us on a tour of the anatomical features that we may have grown or shrunken over the course of our life, according to how we’ve used them, or not. She also looks at what’s going on when it comes to the smaller scale—from the neuronal to the neurochemical.
We learn the truth (and myth) when it comes to left- and right-brainedness, and we learn how whether we saw that dress as black and blue or white and gold, depends on our circadian rhythm (and thus whether we have wired ourselves for perceiving colors more or less often under daylight or artificial light). And lots more.
The style throughout is very accessible, for a book that goes beyond most “how the brain works” books.
Bottom line: if you’re interested in the workings of your brain (as opposed to: a standardized Platonic ideal of what a brain might be), then this book will set you on the right track.
Click here to check out The Neuroscience of You, and learn more about what makes you you!
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Vegetarian & Vegan Diets: Good Or Bad For Brain Health?
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It’s well-established that most people should eat more plants, and generally speaking, less meat. But what about abstaining from meat completely? And what about abstaining from all animal products?
For a more general overview (rather than specifically brain health), check out: Do We Need Animal Products To Be Healthy?
Now, about brains…
Before Homo sapiens was a thing, our precursors such as Homo habilis developed language (thus: greatly enhanced collaborative teamwork) and cooking, resulting in Homo ergaster (who came approximately next in line, give or take taxonomical quibbles) having twice the cranial capacity, generally attributed to being able to acquire and—where appropriate—cook calorie-dense food, which included meat, and also tubers that can’t be safely eaten raw. It’s estimated (based on forensic examination of tooth wear, mineralization, microdeposits of various kinds, etc) that our consumption of animal products in that era was around 10% of our diet (fluctuating by region, of course), but it likely was an important one.
By the time we got to Homo erectus, our skulls (including our cranial cavities, and thus it is presumed, our brains) were actually larger than in Homo sapiens. You may be wondering about Homo neanderthalensis; our cousins (or in some cases, ancestors—but that is beyond the scope of today’s article) also had larger cranial cavities than us, and certainly enjoyed comparatively advanced culture, arts, religion, etc.
Fast-forward to the present day. Nothing is going to meaningfully change our skull size, as individuals. Brain size? Well, keep hydrated or it’ll shrink. Don’t overhydrate or it’ll swell. Neuroplasticity means we can increase (or lose) volume in specific areas of the brain, according to what we do most of. For example, if you were to scan this writer’s brain, you’d probably find overdevelopment in the various areas pertaining to language and memory, as that’s been “my thing” for as long as I can remember (which is a long way). See also: An Underrated Tool Against Alzheimer’s
The impact of diet in the modern day
Unlike our distant ancestors, if we want a high-calorie snack we can buy some nuts from the supermarket, and if anything, this can be a problem (as many people’s go-to high-calorie snack may be a lot less healthy than that), and in turn cause problems for the brain, because too many pizzas, cheeseburgers, tater tots, and so forth cause chronic inflammation, and thus, neuroinflammation.
See also: 6 Worst Foods That Cause Dementia
So much for “calories for the brain”. Yes, the brain definitely needs calories (it expends a very large portion of our daily calorie intake), but you can have too much of a good thing.
In any case, the brain needs more than just calories!
For example, you may remember the “6 Pillars Of Nutritional Psychiatry”, which are:
- Be whole; eat whole
- Eat the rainbow
- The greener, the better
- Tap into your body intelligence
- Consistency & balance are key
- Avoid anxiety-triggering foods
For more on all of those, see Dr. Uma Naidoo’s 6 Pillars Of Nutritional Psychiatry ← She’s a Harvard-trained psychiatrist, professional chef graduating with her culinary school’s most coveted award, and a trained nutritionist. Between those three qualifications, she knows her stuff when it comes to the niche that is nutritional psychiatry.
When it comes to any potential nutritional deficiencies of a vegetarian or vegan diet, it’s a matter of planning.
Properly planned vegetarian diets are rich in essential nutrients like carbohydrates, fiber, magnesium, potassium, folate, vitamins C and E, and an abundance of phytochemicals, which support brain health (and overall health too, but today is about brain health).
However, if not well-planned, they can indeed lack certain nutrients such as vitamin B12, iron, and omega-3 fatty acids, which are critical for brain function.
In essence, there’s a difference between a “whole foods plant-based diet” and junk food that just happens to be vegetarian or vegan.
Vitamin B12 is usually supplemented by vegans, but it can also be enjoyed from nutritional yeast used in cooking (it adds a cheesy flavor to dishes for which that’d be appropriate).
Iron is a fascinating beast, because while everyone thinks of red meat (which is indeed rich in iron), not only are there good plant-based sources of iron, but there are important considerations when it comes to bioavailability differences between heme and non-heme iron. In few words, heme iron (from blood etc) is more bioavailable by 1.8x, but all iron, including non-heme iron (from beans, greens, etc) can have its bioavailability multiplied by 5x just by having it with vitamin C:
Avoiding Anemia (More Than Just “Get More Iron”)
Omega-3 fatty acids, for vegetarians that mostly means eggs. See: Eggs: All Things In Moderation?
For vegans, we must look to nuts and seeds, for the most part. Or supplement—many omega 3 supplements are vegan, made from algae, or seaweed (that in turn is composed partially or entirely of algae):
So really, it comes down to “make sure you still get these things”, and once you’re used to it, it’s easy.
For those who prefer to keep some meat in their diet
Our summary in our top-linked article (Do We Need Animal Products To Be Healthy?) concluded:
- Most of us can live healthily and happily on just plants if we so choose.
- Some people cannot, and will require varying kinds (and quantities) of animal products.
- As for red and/or processed meats, we’re not the boss of you, but from a health perspective, the science is clear: unless you have a circumstance that really necessitates it, just don’t.
- Same goes for pork, which isn’t red and may not be processed, but metabolically it’s associated with the same problems.
- The jury is out on poultry, but it strongly appears to be optional, healthwise, without making much of a difference either way
- Fish is roundly considered healthful in moderation. Enjoy it if you want, don’t if you don’t.
And the paper from which we’ve largely been working from today included such comments as:
❝ Evidence suggests that vegan and vegetarian diets, when well planned, can be rich in phytonutrients and antioxidants, which have been associated with lower levels of inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6). These findings indicate a potential role in reducing systemic inflammation and oxidative stress, both of which are linked to neurodegenerative diseases.
However, deficiencies in critical nutrients such as vitamin B12, DHA, EPA, and iron have been consistently associated with an increased risk of cognitive decline, mood disturbances, and neurodegenerative disorders.
While plant-based diets provide anti-inflammatory and antioxidant benefits, their neurological implications depend on nutrient adequacy. Proper planning, supplementation, and food preparation techniques are essential to mitigate risks and enhance cognitive health.❞
Source: Impact of Vegan and Vegetarian Diets on Neurological Health: A Critical Review ← you can see that they also cover the same nutrients that we do
One final note, not discussed above
We often say “what’s good for your heart is good for your brain”, because the former feeds the latter (with oxygen and nutrients) and assists in cleanup (of detritus that otherwise brings about cognitive decline).
So with that in mind…
What Matters Most For Your Heart? ← hint: it’s fiber. So whether you eat animal products or not, please do eat plenty of plants!
Take care!
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